Provider Demographics
NPI:1811514722
Name:WAGNER, SUSAN M (ARNP, CRNP, FNP-C)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:M
Last Name:WAGNER
Suffix:
Gender:F
Credentials:ARNP, CRNP, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4400 E HIGHWAY 20 STE 207
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-7700
Mailing Address - Country:US
Mailing Address - Phone:850-806-2440
Mailing Address - Fax:334-212-0232
Practice Address - Street 1:4400 E HIGHWAY 20 STE 207
Practice Address - Street 2:
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-7700
Practice Address - Country:US
Practice Address - Phone:850-806-2440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-26
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11007696363LP0200X, 363LF0000X
AL1-097016363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics