Provider Demographics
NPI:1578236170
Name:WAGNER, LACEY DAWN
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:DAWN
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 1:1108 WASHINGTON ST E
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:WV
Mailing Address - Zip Code:24901-2523
Mailing Address - Country:US
Mailing Address - Phone:304-645-2130
Mailing Address - Fax:
Practice Address - Street 1:1108 WASHINGTON ST E
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:WV
Practice Address - Zip Code:24901-2523
Practice Address - Country:US
Practice Address - Phone:304-645-2130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-29
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant