Active NPI
Kelly Lynn Wagnitz, PTA
- Physical Therapy Assistant
- Green Bay, WI
National Provider Identifier
1528230497
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physical Therapy Assistant
- License
- 721-091
- Practice address
- 744 S Webster Ave
Green Bay, WI 54301-3505 - Phone
- (920) 422-7822
- NPI assigned
- Mar 31, 2008
- Last updated
- Mar 31, 2008
- Sex
- Female
- Sole proprietor
- Yes
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 Therapy Assistant | 225200000X | 721-091 | WI | Primary |
Addresses
Primary practice location
744 S Webster Ave
Green Bay, WI 54301-3505
Mailing address
744 S Webster Ave
Green Bay, WI 54301-3505
Phone (920) 336-0890
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 36118700 | Medicaid | WI |
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 |
|---|---|---|---|
| 721-091 | WI | MD | Physical Therapy Assistant |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1206921600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1206921600000",
"number": "1528230497",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "744 S WEBSTER AVE",
"city": "GREEN BAY",
"state": "WI",
"postal_code": "543013505",
"telephone_number": "920-336-0890"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "744 S WEBSTER AVE",
"city": "GREEN BAY",
"state": "WI",
"postal_code": "543013505",
"telephone_number": "920-422-7822"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WAGNITZ",
"first_name": "KELLY",
"middle_name": "LYNN",
"credential": "PTA",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2008-03-31",
"last_updated": "2008-03-31",
"status": "A"
},
"taxonomies": [
{
"code": "225200000X",
"taxonomy_group": "",
"desc": "Physical Therapy Assistant",
"state": "WI",
"license": "721-091",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "36118700",
"state": "WI"
}
],
"endpoints": [],
"other_names": []
}Other providers in Green Bay, WI
- Patrick Nathan Wagner, M.D.
- Robert Harold Wagner, DDS
- Sage Wagner, MS, LCGC
- Samuel Wagner, DC
- William J Wagner, M.D.
- Pamela Lynn Waise, MSN, RN
- Betty Wake, LPN
- Wal-Mart Stores East LP (Wal-Mart Pharmacy 10-1908)
- Wal-Mart Stores East LP (Wal-Mart Pharmacy 10-1453)
- Wal-Mart Stores East, LP (Vision Center 30-1908)
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 31, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.