Provider Demographics
NPI:1841075595
Name:WAGNER, KEELIE MADISON (APRN, CPNP-PC)
Entity type:Individual
Prefix:MRS
First Name:KEELIE
Middle Name:MADISON
Last Name:WAGNER
Suffix:
Gender:F
Credentials:APRN, CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4350 S BROOKLAWN DR
Mailing Address - Street 2:
Mailing Address - City:NEW PALESTINE
Mailing Address - State:IN
Mailing Address - Zip Code:46163-9738
Mailing Address - Country:US
Mailing Address - Phone:317-752-5446
Mailing Address - Fax:
Practice Address - Street 1:5435 EMERSON WAY STE 100
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46226-1470
Practice Address - Country:US
Practice Address - Phone:317-362-0293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-30
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71015385A363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics