Provider Demographics
NPI:1598719924
Name:KRAGNESS, MARY J (AOTA)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:J
Last Name:KRAGNESS
Suffix:
Gender:F
Credentials:AOTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:E9275 780TH AVE
Mailing Address - Street 2:
Mailing Address - City:COLFAX
Mailing Address - State:WI
Mailing Address - Zip Code:54730-5100
Mailing Address - Country:US
Mailing Address - Phone:715-962-3673
Mailing Address - Fax:
Practice Address - Street 1:808 MAIN ST E
Practice Address - Street 2:
Practice Address - City:MENOMONIE
Practice Address - State:WI
Practice Address - Zip Code:54751-2735
Practice Address - Country:US
Practice Address - Phone:715-232-1116
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1308-026225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40529400Medicaid