Provider Demographics
NPI:1497065635
Name:WAGLEY, LAURAL K (NP)
Entity Type:Individual
Prefix:MS
First Name:LAURAL
Middle Name:K
Last Name:WAGLEY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MISS
Other - First Name:LAURAL
Other - Middle Name:K
Other - Last Name:SKINNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:15855 19 MILE RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-3504
Mailing Address - Country:US
Mailing Address - Phone:800-653-6568
Mailing Address - Fax:313-876-1305
Practice Address - Street 1:15855 19 MILE RD
Practice Address - Street 2:
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48038-3504
Practice Address - Country:US
Practice Address - Phone:800-653-6568
Practice Address - Fax:313-876-1305
Is Sole Proprietor?:No
Enumeration Date:2010-10-20
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704207208363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily