Provider Demographics
NPI:1316594674
Name:WAGNER, KAYLEIGH (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:KAYLEIGH
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1443 GREENFIELD DR
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16509-2912
Mailing Address - Country:US
Mailing Address - Phone:814-602-9206
Mailing Address - Fax:
Practice Address - Street 1:501 W 12TH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16501-1536
Practice Address - Country:US
Practice Address - Phone:814-455-3719
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-21
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART0061122083S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083S0010XAllopathic & Osteopathic PhysiciansPreventive MedicineSports Medicine