Provider Demographics
NPI:1427584564
Name:WAGNER, KATHRYN ANN (DC)
Entity Type:Individual
Prefix:DR
First Name:KATHRYN
Middle Name:ANN
Last Name:WAGNER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:838 BROOKMEAD DR
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63366-7572
Mailing Address - Country:US
Mailing Address - Phone:314-606-8044
Mailing Address - Fax:
Practice Address - Street 1:15945 CLAYTON RD STE 230C
Practice Address - Street 2:
Practice Address - City:BALLWIN
Practice Address - State:MO
Practice Address - Zip Code:63011-2491
Practice Address - Country:US
Practice Address - Phone:636-256-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-10
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017013442111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor