Provider Demographics
NPI:1295914331
Name:WAGNER, COURTNEY LEE (LPN)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:LEE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 HOSPITAL DR NE
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32548-5066
Mailing Address - Country:US
Mailing Address - Phone:850-833-9240
Mailing Address - Fax:
Practice Address - Street 1:6261 OLD BETHEL RD
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-5507
Practice Address - Country:US
Practice Address - Phone:850-683-7500
Practice Address - Fax:850-683-7523
Is Sole Proprietor?:No
Enumeration Date:2007-10-25
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN5178468164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse