Individual
KRISTA KATE WAGNER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
OTR
Contact information
Practice address
4770 1ST AVE, HIBBING, MN 55746-3718
(218) 966-7204
Mailing address
4770 1ST AVE, HIBBING, MN 55746-3718
(218) 966-7204
Taxonomy
Speciality
Code
Description
License number
State
225X00000X
Occupational Therapist
Primary
104783
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
616055700
—
MN
Enumeration date
09/09/2015
Last updated
09/09/2015
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