MEDICARE: MS. LORI A WAGNER MSN, APRN

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	363LA2100X	Acute Care Nurse Practitioner	3002772	KY
2	363LA2200X	Adult Health Nurse Practitioner	3002772	KY
3	163W00000X	Registered Nurse	1078503	KY
4	363L00000X	Nurse Practitioner	3002772	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	11221661	OTHER		CAQH
2	1078503	OTHER	KY	REGISTERED NURSE
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	3002772	OTHER	KY	ADVANCED PRACTICE REGISTERED NURSE

General Provider Information

NPI Number	:	1710972260
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LORI A WAGNER MSN, APRN

Provider Business Mailing Address
First Line	:	757 CADEN LN
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40509-4316
Country	:	US
Telephone Number	:	859-797-5558
Fax Number	:	859-368-7780

Provider Business Practice Location Address
First Line	:	2387 PROFESSIONAL HEIGHTS DR STE 180
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40503-3013
Country	:	US
Telephone Number	:	859-967-9486
Fax Number	:	859-368-7780

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

Provider Enumeration Date	:	09/12/2005
Last Update Date	:	07/27/2023

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