Provider Demographics
NPI:1649771445
Name:WAGNER, SHINNAYHA NICOLE
Entity Type:Individual
Prefix:
First Name:SHINNAYHA
Middle Name:NICOLE
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 1:13220 S 48TH ST APT 1112
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85044-5013
Mailing Address - Country:US
Mailing Address - Phone:928-551-1020
Mailing Address - Fax:
Practice Address - Street 1:13220 S 48TH ST APT 1112
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85044-5013
Practice Address - Country:US
Practice Address - Phone:928-551-1020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-27
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7346224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant