Healthcare Provider Details

I. General information

NPI: 1538446117
Provider Name (Legal Business Name): KATHERINE ANN WAGNER RN, FNP-BC, NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2011
Last Update Date: 03/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2951 FULTON AVE
SACRAMENTO CA
95821-4909
US

IV. Provider business mailing address

2951 FULTON AVE
SACRAMENTO CA
95821-4909
US

V. Phone/Fax

Practice location:
  • Phone: 916-486-7555
  • Fax: 916-486-7557
Mailing address:
  • Phone: 916-486-7555
  • Fax: 916-486-7557

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number21313
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number21313
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number21313
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: