Provider Demographics
NPI:1063572717
Name:WAGNER, TERESA MOORE (RN, CDE)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:MOORE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:RN, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 DUNCAN ROAD
Mailing Address - Street 2:
Mailing Address - City:BUCKEYE
Mailing Address - State:WV
Mailing Address - Zip Code:24924-9037
Mailing Address - Country:US
Mailing Address - Phone:304-799-7400
Mailing Address - Fax:304-799-2276
Practice Address - Street 1:150 DUNCAN ROAD
Practice Address - Street 2:
Practice Address - City:BUCKEYE
Practice Address - State:WV
Practice Address - Zip Code:24924-9037
Practice Address - Country:US
Practice Address - Phone:304-799-7400
Practice Address - Fax:304-799-2276
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV30547163WD0400X, 164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator