Active NPI
Kellie Marie Wagner, PT, DPT, CSCS
- Physical Therapist
- Beaver Dam, WI
National Provider Identifier
1144539461
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physical Therapist
- License
- 11507-24
- Practice address
- 1223 Madison St
Beaver Dam, WI 53916-2629 - Phone
- (920) 885-4750
- NPI assigned
- Oct 4, 2010
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physical Therapist | 225100000X | 11507-24 | WI | Primary |
Addresses
Primary practice location
1223 Madison St
Beaver Dam, WI 53916-2629
Mailing address
5002 Autumn Leaf LN Apt 210
Madison, WI 53704-8654
Phone (414) 416-2291
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 11507-24 | WI | MD | Physical Therapist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1286150400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1286150400000",
"number": "1144539461",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "5002 AUTUMN LEAF LN APT 210",
"city": "MADISON",
"state": "WI",
"postal_code": "537048654",
"telephone_number": "414-416-2291"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1223 MADISON ST",
"city": "BEAVER DAM",
"state": "WI",
"postal_code": "539162629",
"telephone_number": "920-885-4750"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WAGNER",
"first_name": "KELLIE",
"middle_name": "MARIE",
"name_prefix": "Dr.",
"credential": "PT, DPT, CSCS",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2010-10-04",
"last_updated": "2010-10-04",
"status": "A"
},
"taxonomies": [
{
"code": "225100000X",
"taxonomy_group": "",
"desc": "Physical Therapist",
"state": "WI",
"license": "11507-24",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Beaver Dam, WI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 4, 2010; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.