Provider Demographics
NPI:1265548242
Name:WAGNER, SHERRY DIANE (LPN)
Entity type:Individual
Prefix:MRS
First Name:SHERRY
Middle Name:DIANE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28020 TANNERS RUN RD
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:OH
Mailing Address - Zip Code:45771-9753
Mailing Address - Country:US
Mailing Address - Phone:740-949-2059
Mailing Address - Fax:740-949-2059
Practice Address - Street 1:28020 TANNERS RUN RD
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:OH
Practice Address - Zip Code:45771-9753
Practice Address - Country:US
Practice Address - Phone:740-949-2059
Practice Address - Fax:740-949-2059
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN085949164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2321302Medicaid