Provider Demographics
NPI:1649097809
Name:WYNN, CRYSTAL (PHD, RD)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:WYNN
Suffix:
Gender:F
Credentials:PHD, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5713 WALNUT WALK DR
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23237-2636
Mailing Address - Country:US
Mailing Address - Phone:804-691-0177
Mailing Address - Fax:
Practice Address - Street 1:5713 WALNUT WALK DR
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23237-2636
Practice Address - Country:US
Practice Address - Phone:804-691-0177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-20
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered