Provider Demographics
NPI:1740054055
Name:WAGNER, KYLIE MONET (OT)
Entity type:Individual
Prefix:DR
First Name:KYLIE
Middle Name:MONET
Last Name:WAGNER
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1421 N 185TH ST
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:NE
Mailing Address - Zip Code:68022-3835
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17024 MORGAN AVE
Practice Address - Street 2:
Practice Address - City:GRETNA
Practice Address - State:NE
Practice Address - Zip Code:68028-3837
Practice Address - Country:US
Practice Address - Phone:402-714-3575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-08
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2826225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist