Provider Demographics
NPI:1245961515
Name:WAGNER, MELANIE LEANNE (MOT)
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:LEANNE
Last Name:WAGNER
Suffix:
Gender:F
Credentials:MOT
Other - Prefix:
Other - First Name:MELANIE
Other - Middle Name:LEANNE
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13299 REDBARN RD
Mailing Address - Street 2:
Mailing Address - City:CAMERON
Mailing Address - State:OK
Mailing Address - Zip Code:74932-2602
Mailing Address - Country:US
Mailing Address - Phone:918-839-4575
Mailing Address - Fax:
Practice Address - Street 1:872 COLLEGE BLVD # 8408
Practice Address - Street 2:
Practice Address - City:OSAGE BEACH
Practice Address - State:MO
Practice Address - Zip Code:65065-8408
Practice Address - Country:US
Practice Address - Phone:573-302-0900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-18
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022022632225X00000X
VA0119009765225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist