Healthcare Provider Details

I. General information

NPI: 1376573923
Provider Name (Legal Business Name): KATHERINE LEIGH WAGNER FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATHERINE HAMMER FNP

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 11/15/2021
Certification Date: 11/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 MAIN ST
HILLSBORO MO
63050-4351
US

IV. Provider business mailing address

3023 N BALLAS RD STE 600D
SAINT LOUIS MO
63131-2332
US

V. Phone/Fax

Practice location:
  • Phone: 636-797-3737
  • Fax: 636-481-2100
Mailing address:
  • Phone: 314-567-7018
  • Fax: 314-567-7048

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1999137599
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1999137599
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: