Provider Demographics
NPI:1538463997
Name:WAGNER, AMY LYN (MOTR/L)
Entity Type:Individual
Prefix:MS
First Name:AMY
Middle Name:LYN
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2820 E 53RD AVE
Mailing Address - Street 2:APT # 48
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99223-7962
Mailing Address - Country:US
Mailing Address - Phone:425-232-4797
Mailing Address - Fax:
Practice Address - Street 1:2820 E 53RD AVE
Practice Address - Street 2:APT # 48
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99223-7962
Practice Address - Country:US
Practice Address - Phone:425-232-4797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-28
Last Update Date:2010-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT60136178225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist