Provider Demographics
NPI:1366438335
Name:WAGNER, MONICA ANN (LAT)
Entity type:Individual
Prefix:
First Name:MONICA
Middle Name:ANN
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8069 COUNTY ROAD A
Mailing Address - Street 2:
Mailing Address - City:LENA
Mailing Address - State:WI
Mailing Address - Zip Code:54139-9737
Mailing Address - Country:US
Mailing Address - Phone:920-842-3280
Mailing Address - Fax:920-430-4746
Practice Address - Street 1:1630 COMMANCHE AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54313-5753
Practice Address - Country:US
Practice Address - Phone:920-430-4750
Practice Address - Fax:920-430-4746
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3450392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer