Healthcare Provider Details

I. General information

NPI: 1053648725
Provider Name (Legal Business Name): KERI NICOLE WAGNER DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2009
Last Update Date: 10/13/2020
Certification Date: 10/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 FOUNDERS WAY STE 1
STRASBURG VA
22657-3791
US

IV. Provider business mailing address

8316 ARLINGTON BLVD SUITE 400
FAIRFAX VA
22031-5207
US

V. Phone/Fax

Practice location:
  • Phone: 540-465-2505
  • Fax: 540-465-2511
Mailing address:
  • Phone: 703-560-3190
  • Fax: 703-560-3194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305206853
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: