Healthcare Provider Details

I. General information

NPI: 1407484025
Provider Name (Legal Business Name): JULIA WYNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2020
Last Update Date: 10/22/2026
Certification Date: 10/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

152 CONANT ST STE 301
BEVERLY MA
01915-2796
US

IV. Provider business mailing address

152 CONANT ST STE 301
BEVERLY MA
01915-2796
US

V. Phone/Fax

Practice location:
  • Phone: 978-927-3030
  • Fax:
Mailing address:
  • Phone: 978-927-3040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: