Provider Demographics
NPI:1043594286
Name:WAGNER, GERARDETTE ANNAMARIE (RN)
Entity type:Individual
Prefix:MS
First Name:GERARDETTE
Middle Name:ANNAMARIE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3638 CENTRAL AVE NE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55418-1343
Mailing Address - Country:US
Mailing Address - Phone:612-378-1474
Mailing Address - Fax:651-378-1570
Practice Address - Street 1:3638 CENTRAL AVE NE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55418-1343
Practice Address - Country:US
Practice Address - Phone:612-378-1474
Practice Address - Fax:612-378-1570
Is Sole Proprietor?:No
Enumeration Date:2011-10-06
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR79199-5163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse