Provider Demographics
NPI:1861460537
Name:WAGGNER, AMY R (RN MSN FNP)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:R
Last Name:WAGGNER
Suffix:
Gender:F
Credentials:RN MSN 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 760
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47501-0760
Mailing Address - Country:US
Mailing Address - Phone:812-254-7310
Mailing Address - Fax:
Practice Address - Street 1:1402 GRAND AVE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:IN
Practice Address - Zip Code:47501-2122
Practice Address - Country:US
Practice Address - Phone:812-257-0383
Practice Address - Fax:812-257-0433
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2021-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001500363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200461840Medicaid
INP00152106OtherMEDICARE RAILROAD
IN000000390541OtherANTHEM
INCA5604OtherMEDICARE RAILROAD GROUP
INCA5604OtherMEDICARE RAILROAD GROUP
INP00152106OtherMEDICARE RAILROAD