MEDICARE: KALEENA WAGNER CGC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	170300000X	Genetic Counselor (M.S.)

General Provider Information

NPI Number	:	1598509374
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KALEENA WAGNER CGC

Provider Business Mailing Address
First Line	:	7251 SYRACUSE DR
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75214-1738
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7777 FOREST LN STE A204
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75230-2583
Country	:	US
Telephone Number	:	972-566-3955
Fax Number	:	469-484-2261

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/25/2024
Last Update Date	:	06/25/2024

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Directions to “ KALEENA WAGNER CGC” Practice Location

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