Healthcare Provider Details

I. General information

NPI: 1841907300
Provider Name (Legal Business Name): NICHOLE J WAGNER OTD, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICHOLE J KRASKA

II. Dates (important events)

Enumeration Date: 11/03/2022
Last Update Date: 03/11/2025
Certification Date: 03/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 E ASH AVE
GLEN ULLIN ND
58631-7138
US

IV. Provider business mailing address

PO BOX 161
GLEN ULLIN ND
58631-0161
US

V. Phone/Fax

Practice location:
  • Phone: 701-348-3107
  • Fax:
Mailing address:
  • Phone: 218-988-2871
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number1961
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: