Provider Demographics
NPI:1821642687
Name:WAGNER, RUTH HATTIE (CRNP)
Entity Type:Individual
Prefix:
First Name:RUTH
Middle Name:HATTIE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6701 AIRPORT BLVD STE D330
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36608-6758
Mailing Address - Country:US
Mailing Address - Phone:251-607-9797
Mailing Address - Fax:251-607-7696
Practice Address - Street 1:3715 DAUPHIN ST STE 4400
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36608-1727
Practice Address - Country:US
Practice Address - Phone:251-607-9797
Practice Address - Fax:251-607-7696
Is Sole Proprietor?:No
Enumeration Date:2019-07-30
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-087424363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner