Individual
BLAIR KELLY WAGNER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
DNP
Contact information
Practice address
4123 DUTCHMANS LN, LOUISVILLE, KY 40207-4707
(502) 333-8855
Mailing address
PO BOX 776351, CHICAGO, IL 60677-6351
(502) 272-5063
(502) 896-2527
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
173292
MT
363L00000X
Nurse Practitioner
Primary
3013869
KY
363LN0000X
Neonatal Nurse Practitioner
3013869
KY
Other
Enumeration date
10/09/2019
Last updated
02/18/2021
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