1487165692 NPI number — LISAMARIE CHRISTY WYNNE SLP

Table of content: LISAMARIE CHRISTY WYNNE SLP (NPI 1487165692)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487165692 NPI number — LISAMARIE CHRISTY WYNNE SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WYNNE
Provider First Name:
LISAMARIE
Provider Middle Name:
CHRISTY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WYNNE
Provider Other First Name:
LISAMARIE
Provider Other Middle Name:
CHRISTY
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
SLP
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1487165692
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/14/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4450 EL CENTRO RD APT 1024
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SACRAMENTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95834-2672
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
501 JESSIE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SACRAMENTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95838-2608
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-922-8855
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/14/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  25060 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)