Provider Demographics
NPI:1053781708
Name:WAGNER, DONNA MARSHA (NP)
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:MARSHA
Last Name:WAGNER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 DEARBORN RD
Mailing Address - Street 2:
Mailing Address - City:PEABODY
Mailing Address - State:MA
Mailing Address - Zip Code:01960-8836
Mailing Address - Country:US
Mailing Address - Phone:978-998-6821
Mailing Address - Fax:
Practice Address - Street 1:10 DEARBORN RD
Practice Address - Street 2:
Practice Address - City:PEABODY
Practice Address - State:MA
Practice Address - Zip Code:01960-8836
Practice Address - Country:US
Practice Address - Phone:978-998-6821
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-06
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-077331163W00000X
ALAG0715073363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No163W00000XNursing Service ProvidersRegistered Nurse