Provider Demographics
NPI:1861643314
Name:VAN WAGNER, OLIVIA C (MA)
Entity Type:Individual
Prefix:MS
First Name:OLIVIA
Middle Name:C
Last Name:VAN WAGNER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MS
Other - First Name:OLIVIA
Other - Middle Name:W,
Other - Last Name:CONYERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:860 LOWER FERRY RD STE 2
Mailing Address - Street 2:
Mailing Address - City:EWING
Mailing Address - State:NJ
Mailing Address - Zip Code:08628-3516
Mailing Address - Country:US
Mailing Address - Phone:609-245-0006
Mailing Address - Fax:
Practice Address - Street 1:860 LOWER FERRY RD STE 2
Practice Address - Street 2:
Practice Address - City:EWING
Practice Address - State:NJ
Practice Address - Zip Code:08628-3516
Practice Address - Country:US
Practice Address - Phone:609-245-0006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-02
Last Update Date:2018-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MG000646000237600000X
NJ41YA00025500231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter