Provider Demographics
NPI:1184872418
Name:WAGNER, DEBRA LYNN (CPNP)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:LYNN
Last Name:WAGNER
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11700 N MERIDIAN ST # C240
Practice Address - Street 2:CENTER FOR CHILDREN'S CANCER AND BLOOD DISEASES
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-4656
Practice Address - Country:US
Practice Address - Phone:317-688-4673
Practice Address - Fax:317-688-3436
Is Sole Proprietor?:No
Enumeration Date:2008-08-28
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000837A363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics