Provider Demographics
NPI:1811340029
Name:WAGNER, MYRANDA MARY
Entity type:Individual
Prefix:
First Name:MYRANDA
Middle Name:MARY
Last Name:WAGNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MYRANDA
Other - Middle Name:MARY
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMP
Mailing Address - Street 1:109 S WATER ST STE 2
Mailing Address - Street 2:
Mailing Address - City:ELLENSBURG
Mailing Address - State:WA
Mailing Address - Zip Code:98926-3061
Mailing Address - Country:US
Mailing Address - Phone:509-962-2225
Mailing Address - Fax:509-962-2270
Practice Address - Street 1:109 S WATER ST STE 2
Practice Address - Street 2:
Practice Address - City:ELLENSBURG
Practice Address - State:WA
Practice Address - Zip Code:98926-3061
Practice Address - Country:US
Practice Address - Phone:509-962-2225
Practice Address - Fax:509-962-2270
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-22
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60440395225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist