Provider Demographics
NPI:1740053339
Name:WAGNER, KAREN
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1253 15TH AVE S
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:IA
Mailing Address - Zip Code:52732-6159
Mailing Address - Country:US
Mailing Address - Phone:563-357-7574
Mailing Address - Fax:
Practice Address - Street 1:1253 15TH AVE S
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:IA
Practice Address - Zip Code:52732-6159
Practice Address - Country:US
Practice Address - Phone:563-357-7574
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-06
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN