Provider Demographics
NPI:1376875732
Name:KELLAM, WYNETTE
Entity Type:Individual
Prefix:
First Name:WYNETTE
Middle Name:
Last Name:KELLAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 DEER RUN RD
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24540-2863
Mailing Address - Country:US
Mailing Address - Phone:434-797-5531
Mailing Address - Fax:434-836-0250
Practice Address - Street 1:175 DEER RUN RD
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24540-2863
Practice Address - Country:US
Practice Address - Phone:434-797-5531
Practice Address - Fax:434-836-0250
Is Sole Proprietor?:No
Enumeration Date:2010-02-09
Last Update Date:2010-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202005654235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004981197Medicaid
VA004981197Medicaid