Provider Demographics
NPI:1023444049
Name:WAGNER, CHERYL ANNE (ARNP)
Entity type:Individual
Prefix:
First Name:CHERYL
Middle Name:ANNE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3450 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2331
Mailing Address - Country:US
Mailing Address - Phone:602-351-6986
Mailing Address - Fax:602-265-8533
Practice Address - Street 1:7600 E FLORENTINE RD
Practice Address - Street 2:
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86314-1295
Practice Address - Country:US
Practice Address - Phone:928-772-1610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-23
Last Update Date:2020-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ227591363LP0808X
IAG078988363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health