Provider Demographics
NPI:1245936533
Name:WAGNER, STACY L (RN)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:L
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:PO BOX 160
Mailing Address - Street 2:
Mailing Address - City:WILMORE
Mailing Address - State:PA
Mailing Address - Zip Code:15962-0160
Mailing Address - Country:US
Mailing Address - Phone:814-915-0430
Mailing Address - Fax:
Practice Address - Street 1:401 BROAD ST
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15906-2745
Practice Address - Country:US
Practice Address - Phone:814-535-6000
Practice Address - Fax:814-248-7901
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-07
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN276830L163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse