Provider Demographics
NPI:1174893606
Name:WYNANTS, KIMBERLY A (MS,CCC,SLP)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:A
Last Name:WYNANTS
Suffix:
Gender:F
Credentials:MS,CCC,SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 259
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:NY
Mailing Address - Zip Code:12022-0259
Mailing Address - Country:US
Mailing Address - Phone:518-658-2515
Mailing Address - Fax:
Practice Address - Street 1:17400 STATE RT. 22
Practice Address - Street 2:
Practice Address - City:CHERRY PLAIN
Practice Address - State:NY
Practice Address - Zip Code:12040-0048
Practice Address - Country:US
Practice Address - Phone:518-658-2515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-30
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005649-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist