Healthcare Provider Details

I. General information

NPI: 1841075595
Provider Name (Legal Business Name): KEELIE MADISON WAGNER APRN, CPNP-PC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2023
Last Update Date: 07/03/2024
Certification Date: 07/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5435 EMERSON WAY STE 100
INDIANAPOLIS IN
46226-1470
US

IV. Provider business mailing address

4350 S BROOKLAWN DR
NEW PALESTINE IN
46163-9738
US

V. Phone/Fax

Practice location:
  • Phone: 317-362-0293
  • Fax:
Mailing address:
  • Phone: 317-752-5446
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number71015385A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: