Provider Demographics
NPI:1104176593
Name:WAGNER, KIMBERLY N (DPT)
Entity type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:N
Last Name:WAGNER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6617 SUNSET PINES ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-4251
Mailing Address - Country:US
Mailing Address - Phone:903-453-1709
Mailing Address - Fax:
Practice Address - Street 1:750 CORONADO CENTER DR
Practice Address - Street 2:SUITE 120
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-5034
Practice Address - Country:US
Practice Address - Phone:702-564-4116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-13
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV27572251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics