Provider Demographics
NPI:1093163784
Name:WAGNER, KIMBERLEE (LVN)
Entity Type:Individual
Prefix:
First Name:KIMBERLEE
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18115 ANDREA CIR N
Mailing Address - Street 2:UNIT 1
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91325-1161
Mailing Address - Country:US
Mailing Address - Phone:818-321-7985
Mailing Address - Fax:
Practice Address - Street 1:16360 ROSCOE BLVD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91406-1219
Practice Address - Country:US
Practice Address - Phone:818-901-4830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-02
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN 271004164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse