Provider Demographics
NPI:1801960588
Name:BAGLEY, KAREN BOULLIANNE (FNP)
Entity type:Individual
Prefix:MS
First Name:KAREN
Middle Name:BOULLIANNE
Last Name:BAGLEY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 W WAINWRIGHT DR
Mailing Address - Street 2:
Mailing Address - City:POQUOSON
Mailing Address - State:VA
Mailing Address - Zip Code:23662-1546
Mailing Address - Country:US
Mailing Address - Phone:757-868-4366
Mailing Address - Fax:
Practice Address - Street 1:416 J CLYDE MORRIS BLVD
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23601-1927
Practice Address - Country:US
Practice Address - Phone:757-594-7400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024039042363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAP08939Medicare UPIN
VA001598C59Medicare ID - Type Unspecified