Provider Demographics
NPI:1740397041
Name:WAGNER, KATHLEEN MARY (ARNP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARY
Last Name:WAGNER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:MARY
Other - Last Name:BENDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:1223 GATEWAY DRIVE
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-2607
Mailing Address - Country:US
Mailing Address - Phone:321-725-4500
Mailing Address - Fax:321-722-1237
Practice Address - Street 1:1223 GATEWAY DRIVE
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-2607
Practice Address - Country:US
Practice Address - Phone:321-725-4500
Practice Address - Fax:321-722-1237
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30000510363L00000X
FLARNP9333175363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9649823Medicaid
WA0212946OtherLABOR & INDUSTRIES
ID807564400Medicaid
WAS64575Medicare UPIN
ID807564400Medicaid