Provider Demographics
NPI:1861990137
Name:SHAFER WAGNER, GRACE (HIS)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:SHAFER WAGNER
Suffix:
Gender:F
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 BALL RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ARDEN
Mailing Address - State:NC
Mailing Address - Zip Code:28704-7800
Mailing Address - Country:US
Mailing Address - Phone:828-550-8158
Mailing Address - Fax:828-299-8023
Practice Address - Street 1:83 S TUNNEL RD STE A7
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28805-2268
Practice Address - Country:US
Practice Address - Phone:828-299-8020
Practice Address - Fax:828-299-8023
Is Sole Proprietor?:No
Enumeration Date:2018-01-31
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1519237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist