Provider Demographics
NPI:1104719970
Name:WAGNER, KARYN ELIZABETH
Entity type:Individual
Prefix:
First Name:KARYN
Middle Name:ELIZABETH
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 1:1385 JEFFREY CT W
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-1278
Mailing Address - Country:US
Mailing Address - Phone:317-403-7997
Mailing Address - Fax:
Practice Address - Street 1:6330 E 75TH ST STE 206
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-2700
Practice Address - Country:US
Practice Address - Phone:317-284-1166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-31
Last Update Date:2025-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05008732A2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Single Specialty