Provider Demographics
NPI:1992030357
Name:WAGONER, KRISTIE LYNN (OTR)
Entity Type:Individual
Prefix:MRS
First Name:KRISTIE
Middle Name:LYNN
Last Name:WAGONER
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2637 LAZY BEND STREET SUITE 105
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77581
Mailing Address - Country:US
Mailing Address - Phone:713-355-0623
Mailing Address - Fax:
Practice Address - Street 1:2637 LAZY BEND ST STE 105
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77581-1007
Practice Address - Country:US
Practice Address - Phone:713-355-0623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-02
Last Update Date:2009-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX110636225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist