Provider Demographics
NPI:1578064382
Name:JOHNSON-WAGNER, TRACIE DENIE (PMHNP-BC)
Entity Type:Individual
Prefix:DR
First Name:TRACIE
Middle Name:DENIE
Last Name:JOHNSON-WAGNER
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4801 E MCDOWELL RD STE 250
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85008-7725
Mailing Address - Country:US
Mailing Address - Phone:602-464-9576
Mailing Address - Fax:480-428-0475
Practice Address - Street 1:2450 E GUADALUPE RD STE 103
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-5116
Practice Address - Country:US
Practice Address - Phone:480-907-6818
Practice Address - Fax:480-428-0475
Is Sole Proprietor?:No
Enumeration Date:2018-02-27
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP11024363LP0808X, 363L00000X
GARN270989363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner