Provider Demographics
NPI:1861738981
Name:WAGNER, KELLY JO
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:JO
Last Name:WAGNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6595 ZINNIA ST
Mailing Address - Street 2:
Mailing Address - City:ARVADA
Mailing Address - State:CO
Mailing Address - Zip Code:80004-2256
Mailing Address - Country:US
Mailing Address - Phone:937-243-1014
Mailing Address - Fax:
Practice Address - Street 1:12650 W 64TH AVE
Practice Address - Street 2:UNIT E501
Practice Address - City:ARVADA
Practice Address - State:CO
Practice Address - Zip Code:80004-3893
Practice Address - Country:US
Practice Address - Phone:303-431-4127
Practice Address - Fax:303-431-4553
Is Sole Proprietor?:No
Enumeration Date:2012-12-17
Last Update Date:2016-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0990570363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care