Provider Demographics
NPI:1801362728
Name:WAGNER, DAYTONA LYNN (LPN)
Entity Type:Individual
Prefix:
First Name:DAYTONA
Middle Name:LYNN
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 CANARSIE TRAIL
Mailing Address - Street 2:
Mailing Address - City:RIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:11961
Mailing Address - Country:US
Mailing Address - Phone:631-452-6088
Mailing Address - Fax:
Practice Address - Street 1:17 BANK AVE
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2703
Practice Address - Country:US
Practice Address - Phone:631-265-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-18
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY333488164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse