Provider Demographics
NPI:1568733442
Name:WAGNER, NEALY E (LPN)
Entity Type:Individual
Prefix:MISS
First Name:NEALY
Middle Name:E
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MISS
Other - First Name:NEALY
Other - Middle Name:E
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:112 BRINKER ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:OH
Mailing Address - Zip Code:44811-1502
Mailing Address - Country:US
Mailing Address - Phone:419-217-8717
Mailing Address - Fax:
Practice Address - Street 1:112 BRINKER ST
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:OH
Practice Address - Zip Code:44811-1502
Practice Address - Country:US
Practice Address - Phone:419-217-8717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-24
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH107717164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse