Provider Demographics
NPI:1578163440
Name:WAGNER, BRANDEN J
Entity Type:Individual
Prefix:
First Name:BRANDEN
Middle Name:J
Last Name:WAGNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:795 S TOWNSHIP ROAD 113
Mailing Address - Street 2:
Mailing Address - City:TIFFIN
Mailing Address - State:OH
Mailing Address - Zip Code:44883-9791
Mailing Address - Country:US
Mailing Address - Phone:419-987-4440
Mailing Address - Fax:
Practice Address - Street 1:795 S TOWNSHIP ROAD 113
Practice Address - Street 2:
Practice Address - City:TIFFIN
Practice Address - State:OH
Practice Address - Zip Code:44883-9791
Practice Address - Country:US
Practice Address - Phone:419-987-4440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-29
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH251X00000X, 253Z00000X, 347C00000X, 376J00000X, 385H00000X
OH7401001251X00000X, 253Z00000X, 347C00000X, 3747P1801X, 385H00000X, 376J00000X
3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No251X00000XAgenciesSupports Brokerage
No253Z00000XAgenciesIn Home Supportive Care
No347C00000XTransportation ServicesPrivate Vehicle
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No385H00000XRespite Care FacilityRespite Care