Individual
JENNY WAGNER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
100 NE RANDOLPH AVE, PEORIA, IL 61606-1919
(309) 624-8500
(309) 624-8552
Mailing address
100 NE RANDOLPH AVE, PEORIA, IL 61606-1919
(309) 624-8500
(309) 624-8552
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
Primary
209.013545
IL
Other
Enumeration date
11/05/2015
Last updated
11/05/2015
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