Provider Demographics
NPI:1104315704
Name:WAGNER, TIA J (RN)
Entity type:Individual
Prefix:MRS
First Name:TIA
Middle Name:J
Last Name:WAGNER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 S NORTON ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-3296
Mailing Address - Country:US
Mailing Address - Phone:765-664-0101
Mailing Address - Fax:765-668-8391
Practice Address - Street 1:317 S NORTON ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-3296
Practice Address - Country:US
Practice Address - Phone:765-664-0101
Practice Address - Fax:765-668-8391
Is Sole Proprietor?:No
Enumeration Date:2018-05-09
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28201834A163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)