MEDICARE: DR. KRISTEN C. WYNNS PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	3484	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1336269349
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KRISTEN C. WYNNS PH.D.

Provider Business Mailing Address
First Line	:	276 VICTORIA HILLS DR S
Second Line	:
City	:	FUQUAY VARINA
State	:	NC
Zip	:	27526-5690
Country	:	US
Telephone Number	:	919-552-7402
Fax Number	:

Provider Business Practice Location Address
First Line	:	1703 LEGION RD
Second Line	:	SUITE 204
City	:	CHAPEL HILL
State	:	NC
Zip	:	27517-2359
Country	:	US
Telephone Number	:	919-805-0182
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/31/2007
Last Update Date	:	07/08/2007

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