Individual
MRS. KATHRYN JANE WAGNER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
FNP-C
Contact information
Practice address
28050 GRAND RIVER AVE, FARMINGTON HILLS, MI 48336-5919
(248) 798-3107
Mailing address
26901 BEAUMONT BLVD STE 3D, SOUTHFIELD, MI 48033-3849
(586) 977-6084
Taxonomy
Speciality
Code
Description
License number
State
363LF0000X
Family Nurse Practitioner
Primary
4704301133
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
4704301133
THE STATE OF MICHIGAN DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS
MI
Enumeration date
08/08/2017
Last updated
03/16/2023
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