Individual
KATHLEEN MARY WAGNER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
ARNP
Contact information
Practice address
1223 GATEWAY DRIVE, MELBOURNE, FL 32901-2607
(321) 725-4500
(321) 722-1237
Mailing address
1223 GATEWAY DRIVE, MELBOURNE, FL 32901-2607
(321) 725-4500
(321) 722-1237
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
AP30000510
WA
363LX0001X
Obstetrics & Gynecology Nurse Practitioner
Primary
ARNP9333175
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0212946
LABOR & INDUSTRIES
WA
05
—
807564400
—
ID
05
—
9649823
—
WA
Enumeration date
08/23/2006
Last updated
09/07/2012
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