Provider Demographics
NPI:1447841879
Name:WAGNER, AMANDA MARIE (FNP)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:MARIE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 955534
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63195-5534
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8670 BIG BEND BLVD STE A
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63119-3839
Practice Address - Country:US
Practice Address - Phone:314-447-1900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-28
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021002285363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily