Provider Demographics
NPI:1326214362
Name:WAGNER, BONNIE KAY
Entity Type:Individual
Prefix:MISS
First Name:BONNIE
Middle Name:KAY
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 1:112 W DELAWARE ST
Mailing Address - Street 2:APT.212
Mailing Address - City:FAIRFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62837-2540
Mailing Address - Country:US
Mailing Address - Phone:618-842-4151
Mailing Address - Fax:
Practice Address - Street 1:112 W DELAWARE ST
Practice Address - Street 2:APT.212
Practice Address - City:FAIRFIELD
Practice Address - State:IL
Practice Address - Zip Code:62837-2540
Practice Address - Country:US
Practice Address - Phone:618-842-4151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-30
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver