Provider Demographics
NPI:1558022236
Name:WAGNER, KAYLA LYNN
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:LYNN
Last Name:WAGNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13226 KOMATITE WAY UNIT 400
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46038-5444
Mailing Address - Country:US
Mailing Address - Phone:502-689-3817
Mailing Address - Fax:
Practice Address - Street 1:9690 E 116TH ST
Practice Address - Street 2:
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46037-2838
Practice Address - Country:US
Practice Address - Phone:317-214-5750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-05
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28230305A163W00000X
IN71012185A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse