Provider Demographics
NPI:1144454612
Name:WAGLE, SALLY L (RN)
Entity type:Individual
Prefix:MRS
First Name:SALLY
Middle Name:L
Last Name:WAGLE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7735 CHANDLER HILL RD
Mailing Address - Street 2:
Mailing Address - City:BOYNE FALLS
Mailing Address - State:MI
Mailing Address - Zip Code:49713
Mailing Address - Country:US
Mailing Address - Phone:269-967-4101
Mailing Address - Fax:
Practice Address - Street 1:7735 CHANDLER HILL RD
Practice Address - Street 2:
Practice Address - City:BOYNE FALLS
Practice Address - State:MI
Practice Address - Zip Code:49713
Practice Address - Country:US
Practice Address - Phone:269-967-4101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-12
Last Update Date:2009-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704169846163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse