Provider Demographics
NPI:1376573923
Name:WAGNER, KATHERINE LEIGH (FNP)
Entity Type:Individual
Prefix:MRS
First Name:KATHERINE
Middle Name:LEIGH
Last Name:WAGNER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:
Other - Last Name:HAMMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:3023 N BALLAS RD STE 600D
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-2332
Mailing Address - Country:US
Mailing Address - Phone:314-567-7018
Mailing Address - Fax:314-567-7048
Practice Address - Street 1:405 MAIN ST
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:MO
Practice Address - Zip Code:63050-4351
Practice Address - Country:US
Practice Address - Phone:636-797-3737
Practice Address - Fax:636-481-2100
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1999137599363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily