Provider Demographics
NPI:1871301721
Name:WAGNER, KANDYSE SHANELL
Entity type:Individual
Prefix:MRS
First Name:KANDYSE
Middle Name:SHANELL
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 1:16229 EDGEWOOD CT
Mailing Address - Street 2:
Mailing Address - City:MAPLE HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44137-3967
Mailing Address - Country:US
Mailing Address - Phone:216-212-6463
Mailing Address - Fax:
Practice Address - Street 1:16229 EDGEWOOD CT
Practice Address - Street 2:
Practice Address - City:MAPLE HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44137-3967
Practice Address - Country:US
Practice Address - Phone:216-212-6463
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-24
Last Update Date:2024-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant