Provider Demographics
NPI:1891596177
Name:WAGNER, KELLY JEAN
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:JEAN
Last Name:WAGNER
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:573 41 1/2 RD
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:NE
Mailing Address - Zip Code:68972-5121
Mailing Address - Country:US
Mailing Address - Phone:402-746-0403
Mailing Address - Fax:
Practice Address - Street 1:573 41 1/2 RD
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:NE
Practice Address - Zip Code:68972-5121
Practice Address - Country:US
Practice Address - Phone:402-746-0403
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-21
Last Update Date:2025-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant