Provider Demographics
NPI:1427769082
Name:WAGNER, CHELSEA (MSN, FNP-BC, RN)
Entity type:Individual
Prefix:MRS
First Name:CHELSEA
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MSN, FNP-BC, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2002 S 11TH ST
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:MI
Mailing Address - Zip Code:49120-4074
Mailing Address - Country:US
Mailing Address - Phone:269-687-0200
Mailing Address - Fax:269-684-0199
Practice Address - Street 1:2002 S 11TH ST
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-4074
Practice Address - Country:US
Practice Address - Phone:269-687-0200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-05
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI47404318133363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner