Provider Demographics
NPI:1841907300
Name:WAGNER, NICHOLE J (OTD, OTR/L)
Entity type:Individual
Prefix:
First Name:NICHOLE
Middle Name:J
Last Name:WAGNER
Suffix:
Gender:F
Credentials:OTD, OTR/L
Other - Prefix:
Other - First Name:NICHOLE
Other - Middle Name:J
Other - Last Name:KRASKA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 161
Mailing Address - Street 2:
Mailing Address - City:GLEN ULLIN
Mailing Address - State:ND
Mailing Address - Zip Code:58631-0161
Mailing Address - Country:US
Mailing Address - Phone:218-988-2871
Mailing Address - Fax:
Practice Address - Street 1:604 E ASH AVE
Practice Address - Street 2:
Practice Address - City:GLEN ULLIN
Practice Address - State:ND
Practice Address - Zip Code:58631-7138
Practice Address - Country:US
Practice Address - Phone:701-348-3107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-03
Last Update Date:2025-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1961225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist