| Doctor Name: | DR. KELLIE MARIE WAGNER |
| NPI Number: | 1144539461 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | PT, DPT, CSCS |
| License Number: | 11507-24 |
| Business Practice Address: | 1223 Madison St Beaver Dam, WI - 539162629 |
| Business Phone Number: | 9208854750 |
| Business Fax Number: | |
| Mailing Address: | 5002 Autumn Leaf Ln Apt 210, MADISON |
| State: | WI |
| Postal Code: | 537048654 |
| Phone Number: | 4144162291 |
| Fax Number: | |
| NPI Enumeration Date: | 10/04/2010 |
| NPI Last Update Date: | 10/04/2010 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 225100000X |
| License Number: | 11507-24 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | WI |
| Taxonomy Type: | Respiratory, Developmental, Rehabilitative and Restorative Service Providers |
| Taxonomy Classification: | Physical Therapist |
| Taxonomy Specialization: | |
| Taxonomy Definition: | (1) Physical therapists are health care professionals who evaluate and treat people with health problems resulting from injury or disease. PT |