Provider Demographics
NPI:1154769396
Name:WAGNER, HOLLY KAY
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:KAY
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 1:2986 KATE BOND RD
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:TN
Mailing Address - Zip Code:38133
Mailing Address - Country:US
Mailing Address - Phone:901-491-2692
Mailing Address - Fax:
Practice Address - Street 1:2986 KATE BOND RD
Practice Address - Street 2:
Practice Address - City:BARTLETT
Practice Address - State:TN
Practice Address - Zip Code:38133-4003
Practice Address - Country:US
Practice Address - Phone:901-491-2692
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-10
Last Update Date:2013-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN0000163346163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse