Provider Demographics
NPI:1649969023
Name:ROSS, KRISTINA LYNN WAGNER (MSN, APRN, FNP-BC)
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:LYNN WAGNER
Last Name:ROSS
Suffix:
Gender:F
Credentials:MSN, APRN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2560 HAUSER ROSS DR STE 425
Mailing Address - Street 2:
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-3194
Mailing Address - Country:US
Mailing Address - Phone:815-784-6300
Mailing Address - Fax:
Practice Address - Street 1:2560 HAUSER ROSS DR STE 425
Practice Address - Street 2:
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178-3194
Practice Address - Country:US
Practice Address - Phone:815-784-6300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-02
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209027267207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine