Provider Demographics
NPI:1447702147
Name:WAGNER, HEIDI
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:545 PLAINFIELD RD STE G-1
Mailing Address - Street 2:
Mailing Address - City:WILLOWBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60527-7600
Mailing Address - Country:US
Mailing Address - Phone:630-205-0101
Mailing Address - Fax:
Practice Address - Street 1:545 PLAINFIELD RD STE G-1
Practice Address - Street 2:
Practice Address - City:WILLOWBROOK
Practice Address - State:IL
Practice Address - Zip Code:60527-7600
Practice Address - Country:US
Practice Address - Phone:708-405-8025
Practice Address - Fax:763-205-9350
Is Sole Proprietor?:No
Enumeration Date:2016-10-28
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209014217363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily