Provider Demographics
NPI:1497533772
Name:WAGNON, JESSICA (BSN, RN, CNOR)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:WAGNON
Suffix:
Gender:F
Credentials:BSN, RN, CNOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 MINTWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:GADSDEN
Mailing Address - State:AL
Mailing Address - Zip Code:35905-1457
Mailing Address - Country:US
Mailing Address - Phone:256-312-5165
Mailing Address - Fax:
Practice Address - Street 1:401 MINTWOOD WAY
Practice Address - Street 2:
Practice Address - City:GADSDEN
Practice Address - State:AL
Practice Address - Zip Code:35905-1457
Practice Address - Country:US
Practice Address - Phone:256-543-5265
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-19
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-122468163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice