Provider Demographics
NPI:1093156564
Name:WAGNER, GWENYTH GRACE
Entity Type:Individual
Prefix:MRS
First Name:GWENYTH
Middle Name:GRACE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 S CLAIRBORNE RD STE 2
Mailing Address - Street 2:
Mailing Address - City:OLATHE
Mailing Address - State:KS
Mailing Address - Zip Code:66062-1774
Mailing Address - Country:US
Mailing Address - Phone:913-730-3661
Mailing Address - Fax:913-768-1944
Practice Address - Street 1:407 S CLAIRBORNE RD
Practice Address - Street 2:
Practice Address - City:OLATHE
Practice Address - State:KS
Practice Address - Zip Code:66062-1857
Practice Address - Country:US
Practice Address - Phone:913-393-9921
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-12
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS53-74969363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health