Provider Demographics
NPI:1821125691
Name:WAGNER, MARTHA E (RN)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:E
Last Name:WAGNER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:MARTI
Other - Middle Name:
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN
Mailing Address - Street 1:410 CYPRESS CREEK CIR
Mailing Address - Street 2:
Mailing Address - City:OLDSMAR
Mailing Address - State:FL
Mailing Address - Zip Code:34677-2009
Mailing Address - Country:US
Mailing Address - Phone:919-475-9983
Mailing Address - Fax:
Practice Address - Street 1:923 BROAD ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-4141
Practice Address - Country:US
Practice Address - Phone:919-475-9983
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC204481163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health