Basic Information
| Provider Information | |||||||||
| NPI: | 1962133074 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAGNER | ||||||||
| FirstName: | KELSEY | ||||||||
| MiddleName: | JO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6404 N 70TH PLZ | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681041074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4025733700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6404 N 70TH PLZ | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681041074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4025373700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2022 | ||||||||
| LastUpdateDate: | 06/20/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | NE | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.