Provider Demographics
NPI:1538446117
Name:WAGNER, KATHERINE ANN (RN, FNP-BC, NP-C)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ANN
Last Name:WAGNER
Suffix:
Gender:F
Credentials:RN, FNP-BC, NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2951 FULTON AVE
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95821-4909
Mailing Address - Country:US
Mailing Address - Phone:916-486-7555
Mailing Address - Fax:916-486-7557
Practice Address - Street 1:2951 FULTON AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95821-4909
Practice Address - Country:US
Practice Address - Phone:916-486-7555
Practice Address - Fax:916-486-7557
Is Sole Proprietor?:No
Enumeration Date:2011-11-09
Last Update Date:2014-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21313363LP2300X, 363LP0808X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1538446117OtherMEDI/MEDI, COMMERCIAL INSURANCE CONTRACTED WITH CLINIC