Healthcare Provider Details

I. General information

NPI: 1366357162
Provider Name (Legal Business Name): KRISTY MARIE WYNN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2026
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1562 DAIRY RD
CHARLOTTESVILLE VA
22903-1304
US

IV. Provider business mailing address

204 W ROSEWOOD DR
BARBOURSVILLE VA
22923-2729
US

V. Phone/Fax

Practice location:
  • Phone: 434-245-2400
  • Fax:
Mailing address:
  • Phone: 815-988-7616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number0119011524
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: