Provider Demographics
NPI:1821085879
Name:WAGNER, CAROLE EATON (FNP)
Entity Type:Individual
Prefix:MRS
First Name:CAROLE
Middle Name:EATON
Last Name:WAGNER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 206
Mailing Address - Street 2:
Mailing Address - City:HUMBOLDT
Mailing Address - State:AZ
Mailing Address - Zip Code:86329-0206
Mailing Address - Country:US
Mailing Address - Phone:928-632-5550
Mailing Address - Fax:
Practice Address - Street 1:500 HWY 89 NORTH
Practice Address - Street 2:NORTHERN AZVA HEALTHCARE SYSTEM
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86313
Practice Address - Country:US
Practice Address - Phone:928-445-4860
Practice Address - Fax:928-776-6147
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-04
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN036104363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily