Provider Demographics
NPI:1154537199
Name:WAGONER-STUMPE, DONNA (CNM)
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:WAGONER-STUMPE
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 JEFFORDS ST
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33756-4024
Mailing Address - Country:US
Mailing Address - Phone:727-446-9100
Mailing Address - Fax:727-446-9900
Practice Address - Street 1:1010 JEFFORDS ST
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33756-4024
Practice Address - Country:US
Practice Address - Phone:727-446-9100
Practice Address - Fax:727-446-9900
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLD216121363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant