Provider Demographics
NPI:1043381981
Name:WRENN, KEVIN (DPT)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:WRENN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3179 BRAVERTON ST
Mailing Address - Street 2:STE 201
Mailing Address - City:EDGEWATER
Mailing Address - State:MD
Mailing Address - Zip Code:21037-2667
Mailing Address - Country:US
Mailing Address - Phone:410-695-1325
Mailing Address - Fax:
Practice Address - Street 1:3179 BRAVERTON ST
Practice Address - Street 2:SUITE 201
Practice Address - City:EDGEWATER
Practice Address - State:MD
Practice Address - Zip Code:21037-2665
Practice Address - Country:US
Practice Address - Phone:410-956-4308
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD19681225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD153M132FMedicare ID - Type Unspecified