Provider Demographics
NPI:1164691465
Name:WAGNER, KIMBERLY H (RN, FNP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:H
Last Name:WAGNER
Suffix:
Gender:F
Credentials:RN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4211 JOE RAMSEY BLVD E
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GREENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75401-7852
Mailing Address - Country:US
Mailing Address - Phone:903-408-7710
Mailing Address - Fax:903-408-7810
Practice Address - Street 1:125 W INTERSTATE 30
Practice Address - Street 2:
Practice Address - City:ROYSE CITY
Practice Address - State:TX
Practice Address - Zip Code:75189-7512
Practice Address - Country:US
Practice Address - Phone:903-408-7700
Practice Address - Fax:903-408-7810
Is Sole Proprietor?:No
Enumeration Date:2008-02-21
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRN 603948363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX220100601Medicaid
TX603948OtherRN FNP LICENSE
TXTXB116489Medicare PIN