Provider Demographics
NPI:1639722903
Name:WAGNER, AMBER (MS-CCC-SLP)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MS-CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1060 CHAPEL HILL RD
Mailing Address - Street 2:
Mailing Address - City:DE QUEEN
Mailing Address - State:AR
Mailing Address - Zip Code:71832-9013
Mailing Address - Country:US
Mailing Address - Phone:870-582-4412
Mailing Address - Fax:
Practice Address - Street 1:130 MEDICAL CIR
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:AR
Practice Address - Zip Code:71852-8606
Practice Address - Country:US
Practice Address - Phone:870-845-8161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-16
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR4258235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty