Healthcare Provider Details

I. General information

NPI: 1639641889
Provider Name (Legal Business Name): KEISHA LYNN WAGNER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2018
Last Update Date: 12/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

273 PUTNAM AVE
BROOKLYN NY
11216-1613
US

IV. Provider business mailing address

273 PUTNAM AVE
BROOKLYN NY
11216-1613
US

V. Phone/Fax

Practice location:
  • Phone: 917-682-4643
  • Fax:
Mailing address:
  • Phone: 917-682-4643
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF343619-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: