Provider Demographics
NPI:1366224776
Name:WAGNER, JILL (FNP-C)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:
Other - Last Name:WEAVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:711 E UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93704-6124
Mailing Address - Country:US
Mailing Address - Phone:559-824-8614
Mailing Address - Fax:
Practice Address - Street 1:250 W 5TH ST
Practice Address - Street 2:
Practice Address - City:HANFORD
Practice Address - State:CA
Practice Address - Zip Code:93230-5029
Practice Address - Country:US
Practice Address - Phone:877-960-3426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-19
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95027454363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily