Provider Demographics
NPI:1487165692
Name:WYNNE, LISAMARIE CHRISTY (SLP)
Entity type:Individual
Prefix:
First Name:LISAMARIE
Middle Name:CHRISTY
Last Name:WYNNE
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:LISAMARIE
Other - Middle Name:CHRISTY
Other - Last Name:WYNNE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:SLP
Mailing Address - Street 1:4450 EL CENTRO RD APT 1024
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95834-2672
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:501 JESSIE AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95838-2608
Practice Address - Country:US
Practice Address - Phone:916-922-8855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-14
Last Update Date:2017-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25060235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist