Grace Elizabeth Wagner, DNP, APRN, CPNP

Primary specialty

Pediatric Nurse PractitionerTaxonomy code 363LP0200X

License

209021274 Issued in IL

Practice address

8600 State Route 91 Ste 200
Peoria, IL 61615-7833

Phone

(309) 692-1030

NPI assigned

Jul 6, 2021

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Eligible to order & refer

• Part B services: No
• Medical equipment: Yes
• Home health: No
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Medicare enrollment (NPD)

Enrolled

Credentials

Certified Pediatric Nurse Practitioner

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1625529600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1625529600000",
    "number": "1871164418",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2223 VETERANS RD UNIT 14",
            "city": "MORTON",
            "state": "IL",
            "postal_code": "615504559",
            "telephone_number": "563-676-5628"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "8600 STATE ROUTE 91 STE 200",
            "city": "PEORIA",
            "state": "IL",
            "postal_code": "616157833",
            "telephone_number": "309-692-1030"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WAGNER",
        "first_name": "GRACE",
        "middle_name": "ELIZABETH",
        "credential": "DNP, APRN, CPNP",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2021-07-06",
        "last_updated": "2021-07-06",
        "certification_date": "2021-07-06",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363LP0200X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Pediatrics",
            "state": "IL",
            "license": "209021274",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Lisa Beth Wade
• Segolene Waechter, BCBA
• Bethany Wagenbach, PTA
• Jill Louise Wagenbach, APRN-BC, CNP
• Benjamin Louis Wagner, DO
• Jenny Wagner
• Julie Wagner
• Mitchel Alan Wagner, DO
• Ellie Marie Waibel, LSW
• Shan Eve Waid, PTA

• Pediatric Nurse Practitioner in Peoria, IL
• Providers in Peoria, IL by specialty
• Pediatric Nurse Practitioner in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 6, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.