Provider Demographics
NPI:1336974641
Name:WEGNER, KYLIE HOPE
Entity type:Individual
Prefix:
First Name:KYLIE
Middle Name:HOPE
Last Name:WEGNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6701 DELAWARE ST
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-3579
Mailing Address - Country:US
Mailing Address - Phone:219-789-3961
Mailing Address - Fax:
Practice Address - Street 1:6701 DELAWARE ST
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-3579
Practice Address - Country:US
Practice Address - Phone:219-789-3961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-05
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN32003811A224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant