Provider Demographics
NPI:1497894133
Name:WAGNER, MUNA ELIZABETH (FNP)
Entity Type:Individual
Prefix:MRS
First Name:MUNA
Middle Name:ELIZABETH
Last Name:WAGNER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 FORREST PARK RD
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30721
Mailing Address - Country:US
Mailing Address - Phone:706-259-3712
Mailing Address - Fax:
Practice Address - Street 1:1413 CHATTANOOGA AVE
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-2631
Practice Address - Country:US
Practice Address - Phone:706-279-2635
Practice Address - Fax:706-279-2679
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2012-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN155078NP363LF0000X
GARN155078363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily