Provider Demographics
NPI:1740953660
Name:WAGONER, ELIZABETH (APRN)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:WAGONER
Suffix:
Gender:F
Credentials:APRN
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 20800
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4105
Mailing Address - Country:US
Mailing Address - Phone:888-402-7256
Mailing Address - Fax:888-902-1099
Practice Address - Street 1:3375 BURNS RD STE 101
Practice Address - Street 2:
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33410-4360
Practice Address - Country:US
Practice Address - Phone:561-622-3618
Practice Address - Fax:561-626-9822
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-27
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FL11014158363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily