Provider Demographics
NPI:1568985539
Name:WAGNER, KAYLEY PACE (APRN)
Entity Type:Individual
Prefix:
First Name:KAYLEY
Middle Name:PACE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:KAYLEY
Other - Middle Name:L
Other - Last Name:PACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:PO BOX 917770
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13330 USF LAUREL DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-6601
Practice Address - Country:US
Practice Address - Phone:813-974-2201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-21
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9361930363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022019500Medicaid
FLP1VGLOtherBLUE CROSS BLUE SHIELD