Provider Demographics
NPI:1134907710
Name:WAGNER, BROOKE MARIE (BSN-RN, PHN)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:MARIE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:BSN-RN, PHN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 GOLF TER
Mailing Address - Street 2:
Mailing Address - City:CROOKSTON
Mailing Address - State:MN
Mailing Address - Zip Code:56716-1107
Mailing Address - Country:US
Mailing Address - Phone:218-289-1057
Mailing Address - Fax:
Practice Address - Street 1:ALTRU CLINIC CROOKSTON
Practice Address - Street 2:400 S MINNESOTA STREET
Practice Address - City:CROOKSTON
Practice Address - State:MN
Practice Address - Zip Code:56716
Practice Address - Country:US
Practice Address - Phone:218-281-9100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-15
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2480220163WC1500X
NDR48895163WP2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
No163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care