Healthcare Provider Details

I. General information

NPI: 1861329732
Provider Name (Legal Business Name): KENYA SHANEL WYNNE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2026
Last Update Date: 05/06/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 BELAIRE AVE STE 102
CHESAPEAKE VA
23320-4686
US

IV. Provider business mailing address

530 BELAIRE AVE STE 102
CHESAPEAKE VA
23320-4686
US

V. Phone/Fax

Practice location:
  • Phone: 757-818-4178
  • Fax:
Mailing address:
  • Phone: 757-818-4178
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: