Provider Demographics
NPI:1346613205
Name:WAGNER, KELLY (ND)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:185 TILLEY DR
Mailing Address - Street 2:SUITE #51
Mailing Address - City:SOUTH BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05403-4484
Mailing Address - Country:US
Mailing Address - Phone:802-860-3366
Mailing Address - Fax:802-497-0461
Practice Address - Street 1:185 TILLEY DR
Practice Address - Street 2:SUITE #51
Practice Address - City:SOUTH BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05403-4484
Practice Address - Country:US
Practice Address - Phone:802-860-3366
Practice Address - Fax:802-497-0461
Is Sole Proprietor?:No
Enumeration Date:2015-11-01
Last Update Date:2015-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT099.0116431175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath