Provider Demographics
NPI:1427935626
Name:WAGNOR, LAURA
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:WAGNOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15949 W WINSLOW AVE
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-9436
Mailing Address - Country:US
Mailing Address - Phone:623-414-1507
Mailing Address - Fax:
Practice Address - Street 1:21258 N 81ST AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-4418
Practice Address - Country:US
Practice Address - Phone:623-412-4900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-19
Last Update Date:2025-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ249191163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool