Provider Demographics
NPI:1255101275
Name:WAGNER, BROOKE
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13029 MONROE MANOR DR
Mailing Address - Street 2:
Mailing Address - City:OAK HILL
Mailing Address - State:VA
Mailing Address - Zip Code:20171-2998
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13029 MONROE MANOR DR
Practice Address - Street 2:
Practice Address - City:OAK HILL
Practice Address - State:VA
Practice Address - Zip Code:20171-2998
Practice Address - Country:US
Practice Address - Phone:703-862-7569
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-02
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program