Provider Demographics
NPI:1689872822
Name:WYRICK, KRISTEN (PT, DPT)
Entity Type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:
Last Name:WYRICK
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2235 RUSSELLVILLE RD
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-5081
Mailing Address - Country:US
Mailing Address - Phone:270-781-1151
Mailing Address - Fax:270-781-1959
Practice Address - Street 1:542 THREE SPRINGS RD
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-7589
Practice Address - Country:US
Practice Address - Phone:270-782-3503
Practice Address - Fax:270-782-1123
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY004858225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY532436OtherANTHEM
KY1689872822OtherTRICARE
KY00394003Medicare PIN