Provider Demographics
NPI:1174992382
Name:WAGNER, MELISSA DALTON (APRN)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:DALTON
Last Name:WAGNER
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 1:34 MEDICAL PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23805-9283
Mailing Address - Country:US
Mailing Address - Phone:804-609-0175
Mailing Address - Fax:804-835-5999
Practice Address - Street 1:34 MEDICAL PARK BLVD
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23805-9283
Practice Address - Country:US
Practice Address - Phone:804-609-0175
Practice Address - Fax:804-835-5999
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-17
Last Update Date:2025-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024184994363LF0000X
KY3009798363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY3009798OtherAPRN LICENSE NUMBER
KY7100385910Medicaid
F0915844OtherAANP CERTIFICATION NUMBER