Provider Demographics
NPI:1447610928
Name:WAGNER, SHAKITA MARIA
Entity Type:Individual
Prefix:
First Name:SHAKITA
Middle Name:MARIA
Last Name:WAGNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHAKITA
Other - Middle Name:MARIA
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1455 CARPATHIAN DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-7974
Mailing Address - Country:US
Mailing Address - Phone:904-524-7263
Mailing Address - Fax:
Practice Address - Street 1:1455 CARPATHIAN DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-7974
Practice Address - Country:US
Practice Address - Phone:904-524-7263
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-26
Last Update Date:2016-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN5213896164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse