Provider Demographics
NPI:1437512175
Name:WYNE, KENNAN MCVEY (DPT)
Entity Type:Individual
Prefix:
First Name:KENNAN
Middle Name:MCVEY
Last Name:WYNE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 IRVINGTON ROAD
Mailing Address - Street 2:PO BOX 128
Mailing Address - City:KILMARNOCK
Mailing Address - State:VA
Mailing Address - Zip Code:22482-0128
Mailing Address - Country:US
Mailing Address - Phone:804-435-3435
Mailing Address - Fax:804-435-3682
Practice Address - Street 1:500 IRVINGTON ROAD
Practice Address - Street 2:
Practice Address - City:KILMARNOCK
Practice Address - State:VA
Practice Address - Zip Code:22482-0128
Practice Address - Country:US
Practice Address - Phone:804-435-3435
Practice Address - Fax:804-435-3682
Is Sole Proprietor?:No
Enumeration Date:2016-03-31
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305210037225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2305210037OtherPT LICENSE