Provider Demographics
NPI:1508311622
Name:WAGNER, SAMANTHA M (RNFA)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:M
Last Name:WAGNER
Suffix:
Gender:F
Credentials:RNFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WELLSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14895-1150
Mailing Address - Country:US
Mailing Address - Phone:585-593-1100
Mailing Address - Fax:
Practice Address - Street 1:191 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WELLSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14895-1150
Practice Address - Country:US
Practice Address - Phone:585-593-1100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-18
Last Update Date:2016-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY552294163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant