Basic Information
| Provider Information | |||||||||
| NPI: | 1952073496 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WYNNE | ||||||||
| FirstName: | KAITLYN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 44513 BAYVIEW AVE APT 9114 | ||||||||
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| City: | CLINTON TWP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480386263 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5865526676 | ||||||||
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| Practice Location | |||||||||
| Address1: | 30330 HICKEY RD | ||||||||
| Address2: | |||||||||
| City: | CHESTERFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480513911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5864214062 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2021 | ||||||||
| LastUpdateDate: | 10/04/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 224Z00000X | 5202008754 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |
No ID Information.