Provider Demographics
NPI:1588037592
Name:WYNN, DOKOTA BOSTON (OTR/L)
Entity Type:Individual
Prefix:
First Name:DOKOTA
Middle Name:BOSTON
Last Name:WYNN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4702 OLD RURAL HALL RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27105-2447
Mailing Address - Country:US
Mailing Address - Phone:336-661-5169
Mailing Address - Fax:
Practice Address - Street 1:720 OLD CHEROKEE RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-9406
Practice Address - Country:US
Practice Address - Phone:336-661-5169
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-12
Last Update Date:2015-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4632225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
349975OtherNCBOT