Provider Demographics
NPI:1710754585
Name:WAGNER, AMY LOUISE (MA)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:LOUISE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3504 INDUSTRIAL AVE STE 214
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-7390
Mailing Address - Country:US
Mailing Address - Phone:907-452-4673
Mailing Address - Fax:
Practice Address - Street 1:3504 INDUSTRIAL AVE STE 214
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-7390
Practice Address - Country:US
Practice Address - Phone:907-452-4673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-11
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health