Provider Demographics
NPI:1689914798
Name:WAGNER, LEILANI LYNN (FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:LEILANI
Middle Name:LYNN
Last Name:WAGNER
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 COFFEE ROAD SUITE 37
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355
Mailing Address - Country:US
Mailing Address - Phone:209-572-7136
Mailing Address - Fax:209-491-7595
Practice Address - Street 1:1800 COFFEE ROAD SUITE 37
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355
Practice Address - Country:US
Practice Address - Phone:209-572-7136
Practice Address - Fax:209-491-7595
Is Sole Proprietor?:No
Enumeration Date:2013-02-26
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN966643363LF0000X
CA95001675363LX0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0106XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerOccupational Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily