Provider Demographics
NPI:1376829994
Name:MASON-WAGAR, KATHY ANN (LPN)
Entity Type:Individual
Prefix:MRS
First Name:KATHY
Middle Name:ANN
Last Name:MASON-WAGAR
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MRS
Other - First Name:KATHY
Other - Middle Name:ANN
Other - Last Name:MASON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:PO BOX 259
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:NY
Mailing Address - Zip Code:12022-0259
Mailing Address - Country:US
Mailing Address - Phone:518-658-2515
Mailing Address - Fax:518-658-0483
Practice Address - Street 1:17400 NY HIGHWAY 22
Practice Address - Street 2:
Practice Address - City:CHERRY PLAIN
Practice Address - State:NY
Practice Address - Zip Code:12040
Practice Address - Country:US
Practice Address - Phone:518-658-2515
Practice Address - Fax:518-658-0483
Is Sole Proprietor?:No
Enumeration Date:2011-10-27
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY115191164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse