Provider Demographics
NPI:1528577053
Name:WAGNER, TONYA MARIE (LPN)
Entity Type:Individual
Prefix:
First Name:TONYA
Middle Name:MARIE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9878 BIG RUN RD
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:OH
Mailing Address - Zip Code:45101-9353
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9878 BIG RUN RD
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:OH
Practice Address - Zip Code:45101-9353
Practice Address - Country:US
Practice Address - Phone:740-463-8109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-27
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.161240.MEDS-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
0OtherN/A