Provider Demographics
NPI:1275379059
Name:WACKERHAGEN, TIA (RN)
Entity type:Individual
Prefix:
First Name:TIA
Middle Name:
Last Name:WACKERHAGEN
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 1:3317 RITCH AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28206-2009
Mailing Address - Country:US
Mailing Address - Phone:417-389-9640
Mailing Address - Fax:
Practice Address - Street 1:3317 RITCH AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28206-2009
Practice Address - Country:US
Practice Address - Phone:417-389-9640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-02
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC335721163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse