Healthcare Provider Details

I. General information

NPI: 1598719924
Provider Name (Legal Business Name): MARY J KRAGNESS AOTA
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

808 MAIN ST E
MENOMONIE WI
54751-2735
US

IV. Provider business mailing address

E9275 780TH AVE
COLFAX WI
54730-5100
US

V. Phone/Fax

Practice location:
  • Phone: 715-232-1116
  • Fax:
Mailing address:
  • Phone: 715-962-3673
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number1308-026
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: