Provider Demographics
NPI:1588342422
Name:WAGNER, CHEYENNE LARK
Entity type:Individual
Prefix:MRS
First Name:CHEYENNE
Middle Name:LARK
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 1:475 IREES WAY
Mailing Address - Street 2:
Mailing Address - City:LONGS
Mailing Address - State:SC
Mailing Address - Zip Code:29568-7232
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:475 IREES WAY
Practice Address - Street 2:
Practice Address - City:LONGS
Practice Address - State:SC
Practice Address - Zip Code:29568-7232
Practice Address - Country:US
Practice Address - Phone:717-916-3170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-10
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician