Provider Demographics
NPI:1477939429
Name:WYNN, PAMELA (PTA)
Entity Type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:
Last Name:WYNN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 ROPE FERRY RD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06385-2610
Mailing Address - Country:US
Mailing Address - Phone:860-444-1175
Mailing Address - Fax:
Practice Address - Street 1:301 ROPE FERRY RD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:CT
Practice Address - Zip Code:06385-2610
Practice Address - Country:US
Practice Address - Phone:860-444-1175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-31
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000528225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant