Provider Demographics
NPI:1316310568
Name:WAGNER, COLLEEN M (A-GNP-C)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:M
Last Name:WAGNER
Suffix:
Gender:F
Credentials:A-GNP-C
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:M
Other - Last Name:GELLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:A-GNP-C
Mailing Address - Street 1:14 RIDGEDALE AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:CEDAR KNOLLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07927-1106
Mailing Address - Country:US
Mailing Address - Phone:973-295-6335
Mailing Address - Fax:
Practice Address - Street 1:14 RIDGEDALE AVE STE 103
Practice Address - Street 2:
Practice Address - City:CEDAR KNOLLS
Practice Address - State:NJ
Practice Address - Zip Code:07927-1106
Practice Address - Country:US
Practice Address - Phone:973-295-6335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-10
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF310566363LA2200X, 363LG0600X
NJ26NJ00855900363LP0808X, 363LA2200X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology