Provider Demographics
NPI:1265783971
Name:WAGNER, PAULA ANNE-MARIE (PT)
Entity type:Individual
Prefix:
First Name:PAULA ANNE-MARIE
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7347
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40257-0347
Mailing Address - Country:US
Mailing Address - Phone:502-974-0173
Mailing Address - Fax:
Practice Address - Street 1:707 RUDY LN
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-2347
Practice Address - Country:US
Practice Address - Phone:502-974-0173
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-21
Last Update Date:2012-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY002031225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist