Healthcare Provider Details

I. General information

NPI: 1417549585
Provider Name (Legal Business Name): KELLY MILLER WYRICK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2021
Last Update Date: 02/09/2021
Certification Date: 02/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 E MAIN ST
WYTHEVILLE VA
24382-3300
US

IV. Provider business mailing address

1137 HUCKLEBERRY RD
CROCKETT VA
24323-3101
US

V. Phone/Fax

Practice location:
  • Phone: 276-228-6200
  • Fax:
Mailing address:
  • Phone: 276-620-4623
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number0119004189
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: