Provider Demographics
NPI:1023623196
Name:WININGER, KAITLYN SHYANNE (LMT)
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:SHYANNE
Last Name:WININGER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1126 E 1350 S
Mailing Address - Street 2:
Mailing Address - City:CLEARFIELD
Mailing Address - State:UT
Mailing Address - Zip Code:84015-1618
Mailing Address - Country:US
Mailing Address - Phone:801-592-6588
Mailing Address - Fax:
Practice Address - Street 1:2180 E 4500 S
Practice Address - Street 2:
Practice Address - City:HOLLADAY
Practice Address - State:UT
Practice Address - Zip Code:84117-4434
Practice Address - Country:US
Practice Address - Phone:801-592-6588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-15
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8457613-4701225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT177635649OtherDRIVER'S LICENSE
UT9807712-0160OtherBUSINESS ENTITY NUMBER