Individual
MARTHA LAINE WAGONER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
FNP
Contact information
Practice address
2102 OTRANTO BLVD, NORTH CHARLESTON, SC 29406-9841
(843) 569-2225
Mailing address
1010 RIVER HAVEN CIR, APT A, CHARLESTON, SC 29412-4121
(731) 610-6718
Taxonomy
Speciality
Code
Description
License number
State
363LF0000X
Family Nurse Practitioner
Primary
19800
SC
Other
Enumeration date
11/30/2015
Last updated
11/30/2015
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