Provider Demographics
NPI:1528858859
Name:WYMORE, OLGA VLADIMIROVNA
Entity type:Individual
Prefix:
First Name:OLGA
Middle Name:VLADIMIROVNA
Last Name:WYMORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2808 NOBLE FIR CT
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-3816
Mailing Address - Country:US
Mailing Address - Phone:804-982-4370
Mailing Address - Fax:
Practice Address - Street 1:13000 HARBOR CENTER DR STE 103
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-2847
Practice Address - Country:US
Practice Address - Phone:804-982-4370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-09
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA24193441363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health