Provider Demographics
NPI:1417598491
Name:WAGNER, MELISSA ANNE (CRNP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANNE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:ANNE
Other - Last Name:GONDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNP
Mailing Address - Street 1:2701 BLAIR MILL RD
Mailing Address - Street 2:SUITE 20
Mailing Address - City:WILLOW GROVE
Mailing Address - State:PA
Mailing Address - Zip Code:19090
Mailing Address - Country:US
Mailing Address - Phone:215-672-7070
Mailing Address - Fax:215-672-6426
Practice Address - Street 1:2701 BLAIR MILL RD
Practice Address - Street 2:SUITE 20
Practice Address - City:WILLOW GROVE
Practice Address - State:PA
Practice Address - Zip Code:19090
Practice Address - Country:US
Practice Address - Phone:215-672-7070
Practice Address - Fax:215-672-6426
Is Sole Proprietor?:No
Enumeration Date:2019-10-01
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP020001363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily