Basic Information
| Provider Information | |||||||||
| NPI: | 1295307791 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | LYNN | ||||||||
| MiddleName: | RENEE | ||||||||
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| Credential: | PMHNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 144 WRECK SHOAL DR | ||||||||
| Address2: | |||||||||
| City: | NEWPORT NEWS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 236061947 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7577195060 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3300 ACADEMY AVE | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 237033205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574836404 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2021 | ||||||||
| LastUpdateDate: | 07/14/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 2021030408 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.