Provider Demographics
NPI:1346459591
Name:WAGNER, JENNIFER ANN (NP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:WAGNER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 FIFTH AVENUE
Mailing Address - Street 2:
Mailing Address - City:NYACK
Mailing Address - State:NY
Mailing Address - Zip Code:10960-1824
Mailing Address - Country:US
Mailing Address - Phone:845-362-1750
Mailing Address - Fax:845-362-1577
Practice Address - Street 1:255 FIFTH AVENUE
Practice Address - Street 2:
Practice Address - City:NYACK
Practice Address - State:NY
Practice Address - Zip Code:10960-1824
Practice Address - Country:US
Practice Address - Phone:845-362-1750
Practice Address - Fax:845-362-1577
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2010-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY334755363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily