Basic Information
| Provider Information | |||||||||
| NPI: | 1063572717 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | TERESA | ||||||||
| MiddleName: | MOORE | ||||||||
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| Credential: | RN, CDE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 150 DUNCAN ROAD | ||||||||
| Address2: | |||||||||
| City: | BUCKEYE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 249249037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047997400 | ||||||||
| FaxNumber: | 3047992276 | ||||||||
| Practice Location | |||||||||
| Address1: | 150 DUNCAN ROAD | ||||||||
| Address2: | |||||||||
| City: | BUCKEYE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 249249037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3047997400 | ||||||||
| FaxNumber: | 3047992276 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2006 | ||||||||
| LastUpdateDate: | 09/23/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WD0400X | 30547 | WV | N | Nursing Service Providers | Registered Nurse | Diabetes Educator | 164W00000X | 30547 | WV | Y | Nursing Service Providers | Licensed Practical Nurse |
No ID Information.