Provider Demographics
NPI:1417279977
Name:SMITH WAGNER, SARAH ROCHELLE (LMP)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:ROCHELLE
Last Name:SMITH WAGNER
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:SARAH
Other - Middle Name:ROCHELLE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:108 S DELAWARE AVE
Mailing Address - Street 2:
Mailing Address - City:WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98801-2609
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:108 S DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98801-2609
Practice Address - Country:US
Practice Address - Phone:509-741-7494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-24
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60129401174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist