Provider Demographics
NPI:1407104060
Name:WAGONER, KRISTEN LARAMIE (NP)
Entity Type:Individual
Prefix:MS
First Name:KRISTEN
Middle Name:LARAMIE
Last Name:WAGONER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 760
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01890-4260
Mailing Address - Country:US
Mailing Address - Phone:781-756-7273
Mailing Address - Fax:781-721-0725
Practice Address - Street 1:500 SALEM ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:MA
Practice Address - Zip Code:01887-1200
Practice Address - Country:US
Practice Address - Phone:978-988-6000
Practice Address - Fax:978-657-4169
Is Sole Proprietor?:No
Enumeration Date:2012-08-29
Last Update Date:2016-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2270616363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner