Provider Demographics
NPI:1912212176
Name:WAGLE, KELLY (DPT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:WAGLE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:MCKENDRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:111 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-2798
Mailing Address - Country:US
Mailing Address - Phone:630-415-3040
Mailing Address - Fax:630-415-3043
Practice Address - Street 1:111 W 3RD ST
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:IL
Practice Address - Zip Code:60126-2798
Practice Address - Country:US
Practice Address - Phone:630-415-3040
Practice Address - Fax:630-415-3043
Is Sole Proprietor?:No
Enumeration Date:2010-08-12
Last Update Date:2016-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-18010225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist