Provider Demographics
NPI:1811528037
Name:WAGONER, MARIAH DANIELLE (APRN)
Entity type:Individual
Prefix:
First Name:MARIAH
Middle Name:DANIELLE
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 1:1713 US HIGHWAY 441 N STE A
Mailing Address - Street 2:
Mailing Address - City:OKEECHOBEE
Mailing Address - State:FL
Mailing Address - Zip Code:34972-1900
Mailing Address - Country:US
Mailing Address - Phone:863-763-5666
Mailing Address - Fax:863-763-0121
Practice Address - Street 1:1713 US HIGHWAY 441 N STE A
Practice Address - Street 2:
Practice Address - City:OKEECHOBEE
Practice Address - State:FL
Practice Address - Zip Code:34972-1900
Practice Address - Country:US
Practice Address - Phone:863-763-5666
Practice Address - Fax:863-763-0121
Is Sole Proprietor?:No
Enumeration Date:2020-01-27
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11005776363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily