Provider Demographics
NPI:1871164418
Name:WAGNER, GRACE ELIZABETH (DNP, APRN, CPNP)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:ELIZABETH
Last Name:WAGNER
Suffix:
Gender:F
Credentials:DNP, APRN, CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2223 VETERANS RD UNIT 14
Mailing Address - Street 2:
Mailing Address - City:MORTON
Mailing Address - State:IL
Mailing Address - Zip Code:61550-4559
Mailing Address - Country:US
Mailing Address - Phone:563-676-5628
Mailing Address - Fax:
Practice Address - Street 1:8600 STATE ROUTE 91 STE 200
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-7833
Practice Address - Country:US
Practice Address - Phone:309-692-1030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-06
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209021274363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics