Provider Demographics
NPI:1508539099
Name:WAGNER, OLIVIA NICOLE (APRN)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:NICOLE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3378 MARINER BLVD # LLC
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34609-2460
Mailing Address - Country:US
Mailing Address - Phone:352-796-7171
Mailing Address - Fax:352-556-4889
Practice Address - Street 1:3378 MARINER BLVD # LLC
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:FL
Practice Address - Zip Code:34609-2460
Practice Address - Country:US
Practice Address - Phone:352-796-7171
Practice Address - Fax:352-556-4889
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-29
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11010750363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily