Basic Information
| Provider Information | |||||||||
| NPI: | 1508539099 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | OLIVIA | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3378 MARINER BLVD # LLC | ||||||||
| Address2: | |||||||||
| City: | SPRING HILL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346092460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3527967171 | ||||||||
| FaxNumber: | 3525564889 | ||||||||
| Practice Location | |||||||||
| Address1: | 3378 MARINER BLVD # LLC | ||||||||
| Address2: | |||||||||
| City: | SPRING HILL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346092460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3527967171 | ||||||||
| FaxNumber: | 3525564889 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2021 | ||||||||
| LastUpdateDate: | 11/03/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 11010750 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.