Provider Demographics
NPI:1417402397
Name:WAGNER, EBONY
Entity type:Individual
Prefix:
First Name:EBONY
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2325 PATTERSON RD
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63031-2205
Mailing Address - Country:US
Mailing Address - Phone:314-620-5553
Mailing Address - Fax:314-584-5002
Practice Address - Street 1:2325 PATTERSON RD
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-2205
Practice Address - Country:US
Practice Address - Phone:314-620-5553
Practice Address - Fax:314-584-5002
Is Sole Proprietor?:No
Enumeration Date:2016-08-19
Last Update Date:2016-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013023536164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse