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General NPI Number Information
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NPI Number | 1740397041
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Entity Type | Individual
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Provider Name | KATHLEEN MARY WAGNER ARNP
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Gender | Female
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Dates
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Enumeration Date | 08/23/2006
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Last Update Date | 09/07/2012
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Provider Practice Location Address
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Address Line | 1223 GATEWAY DRIVE
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City | MELBOURNE
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State | FL
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Zip | 32901-2607
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Country | US
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Telephone | 321-725-4500
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Fax | 321-722-1237
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Provider Business Mailing Address
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Address Line | 1223 GATEWAY DRIVE
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City | MELBOURNE
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State | FL
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Zip | 32901-2607
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Country | US
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Telephone | 321-725-4500
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Fax | 321-722-1237
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | AP30000510
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License Number State | WA
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Taxonomy #2
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Taxonomy Code | 363LX0001X
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Taxonomy Name | Obstetrics & Gynecology Nurse Practitioner
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License Number | ARNP9333175
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License Number State | FL
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