Provider Demographics
NPI:1306212022
Name:WAGNER, TERESA
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 E COLUMBIA AVE.
Mailing Address - Street 2:SUITE 115
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49015
Mailing Address - Country:US
Mailing Address - Phone:269-962-5383
Mailing Address - Fax:269-962-4229
Practice Address - Street 1:131 E COLUMBIA AVE.
Practice Address - Street 2:SUITE 115
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49015
Practice Address - Country:US
Practice Address - Phone:269-962-5383
Practice Address - Fax:269-962-4229
Is Sole Proprietor?:No
Enumeration Date:2015-08-17
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703086736164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse