Individual
MS. MARIE A WAGNER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
365 SW LOG DR, PORT SAINT LUCIE, FL 34953-7501
(772) 785-6473
(772) 408-0998
Mailing address
365 SW LOG DR, PORT SAINT LUCIE, FL 34953-7501
(772) 785-6473
(772) 408-0998
Taxonomy
Speciality
Code
Description
License number
State
171W00000X
Contractor
Primary
19-3549-004-08
FL
Other
Enumeration date
03/18/2008
Last updated
03/18/2008
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