MEDICARE: MRS. KANDYSE SHANELL WAGNER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3747P1801X	Personal Care Attendant

General Provider Information

NPI Number	:	1871301721
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KANDYSE SHANELL WAGNER

Provider Business Mailing Address
First Line	:	16229 EDGEWOOD CT
Second Line	:
City	:	MAPLE HEIGHTS
State	:	OH
Zip	:	44137-3967
Country	:	US
Telephone Number	:	216-212-6463
Fax Number	:

Provider Business Practice Location Address
First Line	:	16229 EDGEWOOD CT
Second Line	:
City	:	MAPLE HEIGHTS
State	:	OH
Zip	:	44137-3967
Country	:	US
Telephone Number	:	216-212-6463
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/24/2024
Last Update Date	:	12/24/2024

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