Provider Demographics
NPI:1487051942
Name:WYNKOOP, KRISTA NICHOLE (MS CCC-SLP/L)
Entity type:Individual
Prefix:MISS
First Name:KRISTA
Middle Name:NICHOLE
Last Name:WYNKOOP
Suffix:
Gender:F
Credentials:MS CCC-SLP/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1035 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-4449
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1035 MADISON ST
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-4449
Practice Address - Country:US
Practice Address - Phone:708-538-4408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-29
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.011558235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist