Provider Demographics
NPI:1851895106
Name:WAGNER, ERICA LYNN
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:LYNN
Last Name:WAGNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:529 NEW GARDEN RD
Mailing Address - Street 2:
Mailing Address - City:NEW PARIS
Mailing Address - State:OH
Mailing Address - Zip Code:45347-9119
Mailing Address - Country:US
Mailing Address - Phone:937-549-7545
Mailing Address - Fax:
Practice Address - Street 1:529 NEW GARDEN RD
Practice Address - Street 2:
Practice Address - City:NEW PARIS
Practice Address - State:OH
Practice Address - Zip Code:45347-9119
Practice Address - Country:US
Practice Address - Phone:937-549-7545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-21
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist