Active NPI
Stephanie Wagner
- Speech-Language Pathologist
- Fairport, NY
National Provider Identifier
1104291574
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Speech-Language Pathologist
- License
- 0217691
- Practice address
- 1387 Fairport Rd
Fairport, NY 14450-2003 - Phone
- (585) 641-0304
- NPI assigned
- Dec 9, 2015
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Speech-Language Pathologist | 235Z00000X | 0217691 | NY | Primary |
Addresses
Primary practice location
1387 Fairport Rd
Fairport, NY 14450-2003
Mailing address
1387 Fairport Rd
Fairport, NY 14450-2003
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in NY
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20160108000047 | NY | Practitioner - Qualified Speech Language Pathologist | 5193027118 |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 0217691 | NY | MD | Speech-Language Pathologist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1449619200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1449619200000",
"number": "1104291574",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1387 FAIRPORT RD",
"city": "FAIRPORT",
"state": "NY",
"postal_code": "144502003"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1387 FAIRPORT RD",
"city": "FAIRPORT",
"state": "NY",
"postal_code": "144502003",
"telephone_number": "585-641-0304"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WAGNER",
"first_name": "STEPHANIE",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2015-12-09",
"last_updated": "2015-12-09",
"status": "A"
},
"taxonomies": [
{
"code": "235Z00000X",
"taxonomy_group": "",
"desc": "Speech-Language Pathologist",
"state": "NY",
"license": "0217691",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Fairport, NY
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 9, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.