Provider Demographics
NPI:1447496500
Name:WAGONER, KATHERINE ANNE (LPN)
Entity type:Individual
Prefix:MRS
First Name:KATHERINE
Middle Name:ANNE
Last Name:WAGONER
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 1:6360 W CENTER AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80226-3401
Mailing Address - Country:US
Mailing Address - Phone:303-347-8848
Mailing Address - Fax:303-997-6123
Practice Address - Street 1:6360 W. CENTER AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80226
Practice Address - Country:US
Practice Address - Phone:303-347-8848
Practice Address - Fax:303-997-6123
Is Sole Proprietor?:No
Enumeration Date:2008-12-19
Last Update Date:2008-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO12867211D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes211D00000XPodiatric Medicine & Surgery Service ProvidersAssistant, Podiatric