Provider Demographics
NPI:1396421558
Name:WYNNE, QUINTIN (PT, DPT)
Entity type:Individual
Prefix:
First Name:QUINTIN
Middle Name:
Last Name:WYNNE
Suffix:
Gender:M
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 1:12531 WOODSTREAM DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63138-1445
Mailing Address - Country:US
Mailing Address - Phone:314-445-9890
Mailing Address - Fax:
Practice Address - Street 1:9560 LEGACY DR STE 210
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75033-6761
Practice Address - Country:US
Practice Address - Phone:214-705-3132
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-23
Last Update Date:2023-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.027559225100000X
TX1378054225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist