Provider Demographics
NPI:1174130629
Name:WAGNER, JESSICA NOEL (FNP-C)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:NOEL
Last Name:WAGNER
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:NOEL
Other - Last Name:CURTIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12517 S TERRAMEER AVE
Mailing Address - Street 2:
Mailing Address - City:HERRIMAN
Mailing Address - State:UT
Mailing Address - Zip Code:84096-5404
Mailing Address - Country:US
Mailing Address - Phone:480-316-2501
Mailing Address - Fax:
Practice Address - Street 1:12828 S 3600 W STE 101
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84065-6853
Practice Address - Country:US
Practice Address - Phone:480-316-2501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-29
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9073204-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily