=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730326794
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AIMEE E WAGNER OTD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/13/2009
-----------------------------------------------------
Last Update Date | 01/13/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1229 C AVE E
-----------------------------------------------------
City | OSKALOOSA
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52577-4246
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 641-672-3306
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1010 D AVE W
-----------------------------------------------------
City | OSKALOOSA
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52577-1930
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-658-9683
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 001936
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------