Provider Demographics
NPI:1679032163
Name:WAGNER, ANGELA MICHELLE (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:MICHELLE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1577 CANTERBURY CT
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OH
Mailing Address - Zip Code:45036-4086
Mailing Address - Country:US
Mailing Address - Phone:513-509-1546
Mailing Address - Fax:
Practice Address - Street 1:3120 BURNET AVE FL 3
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45229-3091
Practice Address - Country:US
Practice Address - Phone:513-585-7700
Practice Address - Fax:513-585-7778
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-14
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.023469363LP0808X
NC5011542363LP0808X
OHAPRNCNP02342084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
2018009202OtherANCC - BOARD CERTIFICATION
OHAPRN.CNP.023469OtherOHIO BOARD OF NURSING ADVANCED PRACTICE LICENSE
NC5011542OtherNORTH CAROLINA STATE BOARD OF NURSING - ADVANCED PRACTICE LICENSE #