Provider Demographics
NPI:1205994621
Name:WAGNER, IRENE K (MA, CCC-A)
Entity type:Individual
Prefix:
First Name:IRENE
Middle Name:K
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MA, CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8020 E CENTRAL AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67206-2380
Mailing Address - Country:US
Mailing Address - Phone:316-634-1100
Mailing Address - Fax:316-634-2928
Practice Address - Street 1:8020 E CENTRAL AVE STE 100
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-2380
Practice Address - Country:US
Practice Address - Phone:316-634-1100
Practice Address - Fax:316-634-2928
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1023231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS115344Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER