Provider Demographics
NPI:1710972260
Name:WAGNER, LORI A (MSN, APRN)
Entity Type:Individual
Prefix:MS
First Name:LORI
Middle Name:A
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MSN, APRN
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:A
Other - Last Name:BROMAGEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:757 CADEN LN
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-4316
Mailing Address - Country:US
Mailing Address - Phone:859-797-5558
Mailing Address - Fax:859-368-7780
Practice Address - Street 1:2387 PROFESSIONAL HEIGHTS DR STE 180
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-3013
Practice Address - Country:US
Practice Address - Phone:859-967-9486
Practice Address - Fax:859-368-7780
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3002772363LA2100X, 363LA2200X, 363L00000X
KY1078503163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
11221661OtherCAQH
KY1078503OtherREGISTERED NURSE
KY78000007Medicaid
KY3002772OtherADVANCED PRACTICE REGISTERED NURSE
11221661OtherCAQH
KY0936601Medicare ID - Type Unspecified
KYP400018687Medicare PIN