Provider Demographics
NPI:1356764658
Name:WAGNER, EMILY LYNN (BSN/RN, DNP/PMHNP)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:LYNN
Last Name:WAGNER
Suffix:
Gender:F
Credentials:BSN/RN, DNP/PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1321 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:VIROQUA
Mailing Address - State:WI
Mailing Address - Zip Code:54665-1156
Mailing Address - Country:US
Mailing Address - Phone:608-637-7052
Mailing Address - Fax:608-785-0002
Practice Address - Street 1:1321 N MAIN ST
Practice Address - Street 2:
Practice Address - City:VIROQUA
Practice Address - State:WI
Practice Address - Zip Code:54665-1156
Practice Address - Country:US
Practice Address - Phone:608-637-7052
Practice Address - Fax:608-785-0002
Is Sole Proprietor?:No
Enumeration Date:2014-01-23
Last Update Date:2025-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI196882-30163W00000X
WI1741533363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse