Provider Demographics
NPI:1821602947
Name:WAGNER, HAILEY LYNN (PT, DPT)
Entity type:Individual
Prefix:
First Name:HAILEY
Middle Name:LYNN
Last Name:WAGNER
Suffix:
Gender:
Credentials:PT, DPT
Other - Prefix:
Other - First Name:HAILEY
Other - Middle Name:LYNN
Other - Last Name:NORRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:1100 CIRCLE 75 PKWY SE STE 1400
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-3067
Mailing Address - Country:US
Mailing Address - Phone:678-981-3543
Mailing Address - Fax:404-777-1311
Practice Address - Street 1:1950 BLUEWATER BLVD STE 100
Practice Address - Street 2:
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-3888
Practice Address - Country:US
Practice Address - Phone:850-807-4200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-04
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT36009208100000X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation