Provider Demographics
NPI:1558496422
Name:WAGNER, CARMENZA (LMT)
Entity Type:Individual
Prefix:
First Name:CARMENZA
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 BEAUMONT LN
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410-2686
Mailing Address - Country:US
Mailing Address - Phone:561-313-9148
Mailing Address - Fax:561-881-2168
Practice Address - Street 1:107 BEAUMONT LN
Practice Address - Street 2:
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33410-2686
Practice Address - Country:US
Practice Address - Phone:561-313-9148
Practice Address - Fax:561-881-2168
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA22533225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist