Provider Demographics
NPI:1750505400
Name:WAGNER, NICOLE M (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27530 TROTTERS RUN
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21801-1819
Mailing Address - Country:US
Mailing Address - Phone:410-742-2979
Mailing Address - Fax:410-742-0106
Practice Address - Street 1:715 E KING ST
Practice Address - Street 2:
Practice Address - City:SEAFORD
Practice Address - State:DE
Practice Address - Zip Code:19973-3505
Practice Address - Country:US
Practice Address - Phone:302-628-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist