Basic Information
| Provider Information | |||||||||
| NPI: | 1134564024 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WONDRA | ||||||||
| FirstName: | VALERIE | ||||||||
| MiddleName: | CHRISTINE | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13410 E BUCKSKIN ST | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672307576 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166553403 | ||||||||
| FaxNumber: | 3162478191 | ||||||||
| Practice Location | |||||||||
| Address1: | 9229 E 37TH ST N STE 201 | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672262003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166553403 | ||||||||
| FaxNumber: | 3162478191 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2013 | ||||||||
| LastUpdateDate: | 12/01/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BC3200X | N | Suppliers | Durable Medical Equipment & Medical Supplies | Customized Equipment | 2251P0200X | 11-02962 | KS | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 201142720A | 05 | KS | MEDICAID |