Individual
KELLY LYNN WAGNITZ
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
PTA
Contact information
Practice address
744 S WEBSTER AVE, GREEN BAY, WI 54301-3505
(920) 422-7822
Mailing address
744 S WEBSTER AVE, GREEN BAY, WI 54301-3505
(920) 336-0890
Taxonomy
Speciality
Code
Description
License number
State
225200000X
Physical Therapy Assistant
Primary
721-091
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
36118700
—
WI
Enumeration date
03/31/2008
Last updated
03/31/2008
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