Provider Demographics
NPI:1407180268
Name:WAGNER, KELLY ANN (LPN)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:ANN
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1143 VOGT DR APT 14
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-5505
Mailing Address - Country:US
Mailing Address - Phone:262-483-8439
Mailing Address - Fax:262-353-3484
Practice Address - Street 1:1143 VOGT DR APT 14
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-5505
Practice Address - Country:US
Practice Address - Phone:262-483-8439
Practice Address - Fax:262-353-3484
Is Sole Proprietor?:No
Enumeration Date:2009-09-28
Last Update Date:2009-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI302197-031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse