Provider Demographics
NPI:1023720455
Name:WAGNER, KAYLA J (FNP)
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:J
Last Name:WAGNER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5434 BRISBANE TRL
Mailing Address - Street 2:
Mailing Address - City:CLAY
Mailing Address - State:NY
Mailing Address - Zip Code:13041-6912
Mailing Address - Country:US
Mailing Address - Phone:315-256-8674
Mailing Address - Fax:
Practice Address - Street 1:421 MONTGOMERY ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13202-2923
Practice Address - Country:US
Practice Address - Phone:315-435-3236
Practice Address - Fax:315-435-3935
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-16
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY720750-01163W00000X
NYF349666-01207Q00000X
NY349666363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine