Provider Demographics
NPI:1699823187
Name:WAGNER, KAREN KAYE (LMP)
Entity Type:Individual
Prefix:MRS
First Name:KAREN
Middle Name:KAYE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1309 NE 103RD CT
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98664-4307
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7904 NE 6TH AVE
Practice Address - Street 2:SUITE C
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98665-8150
Practice Address - Country:US
Practice Address - Phone:360-690-4114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00015471174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist