Provider Demographics
NPI:1164880944
Name:WYNSMA, KAYLA (AGNP)
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:WYNSMA
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 N MAIN ST STE D
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-3281
Mailing Address - Country:US
Mailing Address - Phone:219-663-4888
Mailing Address - Fax:
Practice Address - Street 1:300 N MAIN ST STE D
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-3281
Practice Address - Country:US
Practice Address - Phone:219-663-4888
Practice Address - Fax:219-663-4877
Is Sole Proprietor?:No
Enumeration Date:2016-02-08
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71006398A363LG0600X
IN28216356A163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201377950Medicaid
IN201377950Medicaid
INPENDINGMedicare PIN