Provider Demographics
NPI:1780130955
Name:WAGNER, JANELLE (APRN)
Entity type:Individual
Prefix:
First Name:JANELLE
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:JANELLE
Other - Middle Name:
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:APRN
Mailing Address - Street 1:14501 PADDINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73142-7803
Mailing Address - Country:US
Mailing Address - Phone:405-834-5282
Mailing Address - Fax:
Practice Address - Street 1:13301 N MERIDIAN AVE STE 300A
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-8357
Practice Address - Country:US
Practice Address - Phone:405-849-5391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-28
Last Update Date:2024-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0058475363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner