Provider Demographics
NPI:1699199919
Name:WAGNER, VALERIE ANN (RN-PHN)
Entity Type:Individual
Prefix:
First Name:VALERIE
Middle Name:ANN
Last Name:WAGNER
Suffix:
Gender:F
Credentials:RN-PHN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 W MAIN ST STE 200
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MN
Mailing Address - Zip Code:56258-3171
Mailing Address - Country:US
Mailing Address - Phone:320-510-5676
Mailing Address - Fax:507-537-6719
Practice Address - Street 1:607 W MAIN ST STE 200
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MN
Practice Address - Zip Code:56258-3171
Practice Address - Country:US
Practice Address - Phone:320-510-5676
Practice Address - Fax:507-537-6719
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-06
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR-135369-1163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health