Provider Demographics
NPI:1528879327
Name:WINN, WYATT
Entity type:Individual
Prefix:
First Name:WYATT
Middle Name:
Last Name:WINN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11124 FRONT ST
Mailing Address - Street 2:
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-1525
Mailing Address - Country:US
Mailing Address - Phone:708-478-9850
Mailing Address - Fax:630-812-0780
Practice Address - Street 1:11124 FRONT ST
Practice Address - Street 2:
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448-1525
Practice Address - Country:US
Practice Address - Phone:708-478-9850
Practice Address - Fax:630-812-0780
Is Sole Proprietor?:No
Enumeration Date:2025-01-20
Last Update Date:2025-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.014254111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor