Provider Demographics
NPI:1639702228
Name:WAGNER-RICHARDSON, MARIA-GRETCHEN FABROA (RN)
Entity Type:Individual
Prefix:
First Name:MARIA-GRETCHEN
Middle Name:FABROA
Last Name:WAGNER-RICHARDSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5735 DURAND AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:WI
Mailing Address - Zip Code:53406-5011
Mailing Address - Country:US
Mailing Address - Phone:262-598-1392
Mailing Address - Fax:
Practice Address - Street 1:5735 DURAND AVE
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53406-5011
Practice Address - Country:US
Practice Address - Phone:262-598-1392
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-21
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI251755-30163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)