Provider Demographics
NPI:1053648725
Name:WAGNER, KERI NICOLE (DPT)
Entity Type:Individual
Prefix:
First Name:KERI
Middle Name:NICOLE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8316 ARLINGTON BLVD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-5207
Mailing Address - Country:US
Mailing Address - Phone:703-560-3190
Mailing Address - Fax:703-560-3194
Practice Address - Street 1:100 FOUNDERS WAY STE 1
Practice Address - Street 2:
Practice Address - City:STRASBURG
Practice Address - State:VA
Practice Address - Zip Code:22657-3791
Practice Address - Country:US
Practice Address - Phone:540-465-2505
Practice Address - Fax:540-465-2511
Is Sole Proprietor?:No
Enumeration Date:2009-11-17
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305206853225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist