Provider Demographics
NPI:1508748013
Name:WAGNER, KARLY KATHLEEN (LPN)
Entity type:Individual
Prefix:
First Name:KARLY
Middle Name:KATHLEEN
Last Name:WAGNER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4605 MIDDLE URBANA RD
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:OH
Mailing Address - Zip Code:43078-8228
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5460 CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43231-4074
Practice Address - Country:US
Practice Address - Phone:614-568-8236
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-24
Last Update Date:2025-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.109024.MEDS164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse