Provider Demographics
NPI:1568858793
Name:WAGNER-SMITH, MICHELLE (MSN, AGPCNP-BC)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:WAGNER-SMITH
Suffix:
Gender:F
Credentials:MSN, AGPCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5780 STEWART RD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48162-9700
Mailing Address - Country:US
Mailing Address - Phone:734-915-6265
Mailing Address - Fax:
Practice Address - Street 1:JOHN D. DINGELL VAMC
Practice Address - Street 2:4646 JOHN R STREET
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-1916
Practice Address - Country:US
Practice Address - Phone:313-576-4645
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-14
Last Update Date:2015-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704204786363LP2300X, 363LG0600X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health