Basic Information
| Provider Information | |||||||||
| NPI: | 1407049430 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | WYNN | ||||||||
| FirstName: | KENNETTE | ||||||||
| MiddleName: | R. | ||||||||
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| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15202 GRAND SUMMIT BLVD APT 204 | ||||||||
| Address2: | |||||||||
| City: | GRANDVIEW | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640302790 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4173997339 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10300 W 103RD ST | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | OVERLAND PARK | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662142642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9138941910 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2007 | ||||||||
| LastUpdateDate: | 08/22/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2006001837 | MO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 2006001837 | 01 | MO | STATE LICENSE | OTHER |