Healthcare Provider Details

I. General information

NPI: 1639800980
Provider Name (Legal Business Name): KACI BROOKE WAGLER FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2022
Last Update Date: 07/25/2023
Certification Date: 07/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 CARTER PARK DR
SENECA SC
29678-1152
US

IV. Provider business mailing address

300 E MCBEE AVE FL 4
GREENVILLE SC
29601-2842
US

V. Phone/Fax

Practice location:
  • Phone: 864-482-2360
  • Fax: 864-482-2365
Mailing address:
  • Phone: 864-522-8603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number27507
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: