Provider Demographics
NPI:1538052113
Name:WAGNER, CANDICE ASHLEY (RN)
Entity type:Individual
Prefix:MRS
First Name:CANDICE
Middle Name:ASHLEY
Last Name:WAGNER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MRS
Other - First Name:CANDICE
Other - Middle Name:ASHLEY
Other - Last Name:WOODS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN
Mailing Address - Street 1:17 TIMOTHY LN
Mailing Address - Street 2:
Mailing Address - City:TINTON FALLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07724-3133
Mailing Address - Country:US
Mailing Address - Phone:347-703-9010
Mailing Address - Fax:
Practice Address - Street 1:80 WILLOWBROOK CT
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10302-2402
Practice Address - Country:US
Practice Address - Phone:718-981-0502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-02
Last Update Date:2025-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY717701163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse