Provider Demographics
NPI:1992471437
Name:WAGNER, GWENDOLYN DIANNE (RN, DNP, FNP)
Entity type:Individual
Prefix:DR
First Name:GWENDOLYN
Middle Name:DIANNE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:RN, DNP, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 801749
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARITA
Mailing Address - State:CA
Mailing Address - Zip Code:91380-1749
Mailing Address - Country:US
Mailing Address - Phone:818-259-2732
Mailing Address - Fax:
Practice Address - Street 1:26045 SHADOW ROCK LN
Practice Address - Street 2:
Practice Address - City:VALENCIA
Practice Address - State:CA
Practice Address - Zip Code:91381-0632
Practice Address - Country:US
Practice Address - Phone:818-259-2732
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-16
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA406827163WG0000X
CA95018063363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice