Provider Demographics
NPI:1508482035
Name:WAGNER, ELLA (DNP-FNP)
Entity Type:Individual
Prefix:
First Name:ELLA
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:DNP-FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1945 N HALSTED ST
Mailing Address - Street 2:101
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614
Mailing Address - Country:US
Mailing Address - Phone:872-245-6863
Mailing Address - Fax:
Practice Address - Street 1:1945 N HALSTED ST
Practice Address - Street 2:101
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614
Practice Address - Country:US
Practice Address - Phone:872-245-6863
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-20
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209023655363L00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner