Provider Demographics
NPI:1609157569
Name:WAGNER, PHYLLIS A (ARNP)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:A
Last Name:WAGNER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3390 SW 131ST TER
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33330-4618
Mailing Address - Country:US
Mailing Address - Phone:954-424-0346
Mailing Address - Fax:954-370-4833
Practice Address - Street 1:3390 SW 131ST TER
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33330-4618
Practice Address - Country:US
Practice Address - Phone:954-424-0346
Practice Address - Fax:954-370-4833
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-06
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 670502363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily