Provider Demographics
NPI:1144951864
Name:KIPP, WYATT JAMES (DPT)
Entity type:Individual
Prefix:
First Name:WYATT
Middle Name:JAMES
Last Name:KIPP
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11435 GERTRUDE CT APT 201
Mailing Address - Street 2:
Mailing Address - City:LA VISTA
Mailing Address - State:NE
Mailing Address - Zip Code:68128-4794
Mailing Address - Country:US
Mailing Address - Phone:308-655-0645
Mailing Address - Fax:
Practice Address - Street 1:1702 HILLCREST DR
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:NE
Practice Address - Zip Code:68005-3652
Practice Address - Country:US
Practice Address - Phone:402-291-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-22
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE4332225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist