Healthcare Provider Details

I. General information

NPI: 1437272150
Provider Name (Legal Business Name): KIMBERLY DAWN WAGNER PHARM.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 03/10/2025
Certification Date: 03/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 S CLINTON ST
BALTIMORE MD
21224-5730
US

IV. Provider business mailing address

1501 S CLINTON ST
BALTIMORE MD
21224-5730
US

V. Phone/Fax

Practice location:
  • Phone: 443-555-5555
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number14962
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: