Provider Demographics
NPI:1417769373
Name:WAGNER, MADELYN ROSE
Entity type:Individual
Prefix:
First Name:MADELYN
Middle Name:ROSE
Last Name:WAGNER
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1729 LEE DR
Mailing Address - Street 2:
Mailing Address - City:WOODLAND
Mailing Address - State:CA
Mailing Address - Zip Code:95776-5134
Mailing Address - Country:US
Mailing Address - Phone:916-214-4037
Mailing Address - Fax:
Practice Address - Street 1:1729 LEE DR
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95776-5134
Practice Address - Country:US
Practice Address - Phone:916-214-4037
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-27
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist