Provider Demographics
NPI:1528610466
Name:WAGNER, KRISTINA R
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:R
Last Name:WAGNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KRISTINA
Other - Middle Name:W
Other - Last Name:DALY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1436 BROADRICK DR STE B
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-3009
Mailing Address - Country:US
Mailing Address - Phone:706-226-3434
Mailing Address - Fax:706-226-4820
Practice Address - Street 1:1436 BROADRICK DR STE B
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-3009
Practice Address - Country:US
Practice Address - Phone:706-226-3434
Practice Address - Fax:706-226-4820
Is Sole Proprietor?:No
Enumeration Date:2019-07-11
Last Update Date:2024-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN135155363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily