Individual
GRACE ELIZABETH WAGNER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
DNP, APRN, CPNP
Contact information
Practice address
8600 STATE ROUTE 91 STE 200, PEORIA, IL 61615-7833
(309) 692-1030
Mailing address
2223 VETERANS RD UNIT 14, MORTON, IL 61550-4559
(563) 676-5628
Taxonomy
Speciality
Code
Description
License number
State
363LP0200X
Pediatric Nurse Practitioner
Primary
209021274
IL
Other
Enumeration date
07/06/2021
Last updated
07/06/2021
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