Provider Demographics
NPI:1871652271
Name:WAGNER, LORETTA ANN (STNA)
Entity Type:Individual
Prefix:MRS
First Name:LORETTA
Middle Name:ANN
Last Name:WAGNER
Suffix:
Gender:F
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8473 LEAVER AVE NW
Mailing Address - Street 2:
Mailing Address - City:CANAL FULTON
Mailing Address - State:OH
Mailing Address - Zip Code:44614-8871
Mailing Address - Country:US
Mailing Address - Phone:330-854-6597
Mailing Address - Fax:330-854-6597
Practice Address - Street 1:8473 LEAVER AVE NW
Practice Address - Street 2:
Practice Address - City:CANAL FULTON
Practice Address - State:OH
Practice Address - Zip Code:44614-8871
Practice Address - Country:US
Practice Address - Phone:330-854-6597
Practice Address - Fax:330-854-6597
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH501043601105376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide