Basic Information
| Provider Information | |||||||||
| NPI: | 1629220447 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | KATHIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4901 NORTHSHORE DR | ||||||||
| Address2: | |||||||||
| City: | NORTH LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721185293 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5017913331 | ||||||||
| FaxNumber: | 5017910294 | ||||||||
| Practice Location | |||||||||
| Address1: | 4901 NORTHSHORE DR | ||||||||
| Address2: | |||||||||
| City: | NORTH LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721185293 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5017913331 | ||||||||
| FaxNumber: | 5017910294 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2008 | ||||||||
| LastUpdateDate: | 10/13/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.