Individual
KELLI JO WAGNER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PT
Contact information
Practice address
2500 E PROSPECT RD, FORT COLLINS, CO 80525-9718
(970) 493-0112
Mailing address
2500 E PROSPECT RD, FORT COLLINS, CO 80525-9718
(970) 493-0112
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
PTL.0007418
CO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
56634315
—
CO
Enumeration date
03/13/2008
Last updated
10/14/2014
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