Provider Demographics
NPI:1336269349
Name:WYNNS, KRISTEN C (PHD)
Entity Type:Individual
Prefix:DR
First Name:KRISTEN
Middle Name:C
Last Name:WYNNS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:276 VICTORIA HILLS DR S
Mailing Address - Street 2:
Mailing Address - City:FUQUAY VARINA
Mailing Address - State:NC
Mailing Address - Zip Code:27526-5690
Mailing Address - Country:US
Mailing Address - Phone:919-552-7402
Mailing Address - Fax:
Practice Address - Street 1:1703 LEGION RD
Practice Address - Street 2:SUITE 204
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27517-2359
Practice Address - Country:US
Practice Address - Phone:919-805-0182
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3484103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6000889Medicaid