Provider Demographics
NPI:1659744316
Name:WAGNER, KELLY ANN (FNP-C, APRN)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:WAGNER
Suffix:
Gender:F
Credentials:FNP-C, APRN
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ANN
Other - Last Name:GAITHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:18 S CROMWELL RD
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31410-4421
Mailing Address - Country:US
Mailing Address - Phone:410-652-7666
Mailing Address - Fax:912-216-3436
Practice Address - Street 1:1395 EISENHOWER DR
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-3901
Practice Address - Country:US
Practice Address - Phone:912-356-2441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-03
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN266801363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily