Individual
KELSEY ANNA WAGONER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
FNP
Contact information
Practice address
209 E JEFFERSON ST, PLYMOUTH, IN 46563-1861
(574) 948-5100
(574) 335-0745
Mailing address
707 CEDAR ST STE 405, SOUTH BEND, IN 46617-2059
Taxonomy
Speciality
Code
Description
License number
State
363LF0000X
Family Nurse Practitioner
Primary
71013346A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1102690702
ANTHEM
IN
05
—
300070012
—
IN
Enumeration date
09/12/2022
Last updated
11/09/2023
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