Healthcare Provider Details

I. General information

NPI: 1104176593
Provider Name (Legal Business Name): KIMBERLY N WAGNER DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2012
Last Update Date: 09/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 CORONADO CENTER DR SUITE 120
HENDERSON NV
89052-5034
US

IV. Provider business mailing address

6617 SUNSET PINES ST
LAS VEGAS NV
89148-4251
US

V. Phone/Fax

Practice location:
  • Phone: 702-564-4116
  • Fax:
Mailing address:
  • Phone: 903-453-1709
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number2757
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: