Provider Demographics
NPI:1134334386
Name:WYNKOOP, LISA ANNE (PTA)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ANNE
Last Name:WYNKOOP
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 1:9729 MARCY RD
Mailing Address - Street 2:
Mailing Address - City:CANAL WINCHESTER
Mailing Address - State:OH
Mailing Address - Zip Code:43110-9511
Mailing Address - Country:US
Mailing Address - Phone:614-837-1112
Mailing Address - Fax:
Practice Address - Street 1:391 CLARK DR
Practice Address - Street 2:
Practice Address - City:CIRCLEVILLE
Practice Address - State:OH
Practice Address - Zip Code:43113-1561
Practice Address - Country:US
Practice Address - Phone:740-474-6036
Practice Address - Fax:740-420-3342
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA 3919225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant