Healthcare Provider Details

I. General information

NPI: 1609338136
Provider Name (Legal Business Name): KEREN WAGNER DNP, CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2019
Last Update Date: 02/25/2025
Certification Date: 02/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2105 E SOUTH BLVD
MONTGOMERY AL
36116-2409
US

IV. Provider business mailing address

113 S PERRY ST STE 206
LAWRENCEVILLE GA
30046-4811
US

V. Phone/Fax

Practice location:
  • Phone: 334-288-2100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN597039
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN.CRNA.019970
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1-200299
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: