Provider Demographics
NPI:1699001917
Name:ROBERSON WYNNE, KATHRYN DAVIS (PTA)
Entity Type:Individual
Prefix:MRS
First Name:KATHRYN
Middle Name:DAVIS
Last Name:ROBERSON WYNNE
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 1:1124 CEDAR HILL DR
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTON
Mailing Address - State:NC
Mailing Address - Zip Code:27892-8690
Mailing Address - Country:US
Mailing Address - Phone:252-792-1791
Mailing Address - Fax:
Practice Address - Street 1:1124 CEDAR HILL DR
Practice Address - Street 2:
Practice Address - City:WILLIAMSTON
Practice Address - State:NC
Practice Address - Zip Code:27892-8690
Practice Address - Country:US
Practice Address - Phone:252-792-1791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-21
Last Update Date:2009-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1474225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant