Provider Demographics
NPI:1689049033
Name:WAGNER, CRYSTAL (APRN)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:
Other - Last Name:CRUZE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 18667
Mailing Address - Street 2:
Mailing Address - City:ERLANGER
Mailing Address - State:KY
Mailing Address - Zip Code:41018-0667
Mailing Address - Country:US
Mailing Address - Phone:513-312-2247
Mailing Address - Fax:859-572-2326
Practice Address - Street 1:85 N GRAND AVE
Practice Address - Street 2:
Practice Address - City:FORT THOMAS
Practice Address - State:KY
Practice Address - Zip Code:41075-1793
Practice Address - Country:US
Practice Address - Phone:859-572-3617
Practice Address - Fax:859-572-2326
Is Sole Proprietor?:No
Enumeration Date:2015-12-10
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3009831363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100411630Medicaid
OH0229162Medicaid