Provider Demographics
NPI:1346584539
Name:WAGNER, LAURA BETH (N D)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:BETH
Last Name:WAGNER
Suffix:
Gender:F
Credentials:N D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:335 N MADISON ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:WA
Mailing Address - Zip Code:98272-1410
Mailing Address - Country:US
Mailing Address - Phone:425-244-2685
Mailing Address - Fax:
Practice Address - Street 1:101 E MAIN ST
Practice Address - Street 2:SUITE 201
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272-1519
Practice Address - Country:US
Practice Address - Phone:360-863-0642
Practice Address - Fax:360-794-7236
Is Sole Proprietor?:No
Enumeration Date:2012-11-12
Last Update Date:2012-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANT60322752175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath