Basic Information
| Provider Information | |||||||||
| NPI: | 1407104060 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAGONER | ||||||||
| FirstName: | KRISTEN | ||||||||
| MiddleName: | LARAMIE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 760 | ||||||||
| Address2: | |||||||||
| City: | WINCHESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018904260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7817567273 | ||||||||
| FaxNumber: | 7817210725 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 SALEM ST | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018871200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9789886000 | ||||||||
| FaxNumber: | 9786574169 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2012 | ||||||||
| LastUpdateDate: | 06/10/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 2270616 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.