Provider Demographics
NPI:1417974395
Name:WAGNER, ELAINE JANET (DC)
Entity Type:Individual
Prefix:MS
First Name:ELAINE
Middle Name:JANET
Last Name:WAGNER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6033 N SHERIDAN RD # CW04S-05
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60660-3003
Mailing Address - Country:US
Mailing Address - Phone:773-274-6827
Mailing Address - Fax:
Practice Address - Street 1:6033 N SHERIDAN RD # CW04S-05
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60660-3003
Practice Address - Country:US
Practice Address - Phone:773-274-6827
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038004140111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor