Provider Demographics
NPI:1871188474
Name:WAGNER, HEATHER M (RN)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:M
Last Name:WAGNER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6400 E BROAD ST FL 4
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43213-2086
Mailing Address - Country:US
Mailing Address - Phone:614-655-3345
Mailing Address - Fax:
Practice Address - Street 1:6400 E BROAD ST FL 4
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-2086
Practice Address - Country:US
Practice Address - Phone:614-655-3345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-05
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.439790163W00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No171M00000XOther Service ProvidersCase Manager/Care Coordinator