Individual
KIMBERLY MARIE WAGNER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
AT
Contact information
Practice address
59 EXECUTIVE PARK S STE 1100, ATLANTA, GA 30329-2208
(404) 778-6330
(404) 778-6370
Mailing address
8259 WICKER AVE, SAINT JOHN, IN 46373-8878
(219) 635-6560
(219) 365-6561
Taxonomy
Speciality
Code
Description
License number
State
2255A2300X
Athletic Trainer
Primary
AT002993
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
AT002993
GEORGIA BOARD OF AT
GA
Enumeration date
08/02/2017
Last updated
08/02/2017
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