Provider Demographics
NPI:1487243002
Name:WYANT, EMILY LYNNE (BOND HAIR BAR)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:LYNNE
Last Name:WYANT
Suffix:
Gender:F
Credentials:BOND HAIR BAR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 DE ANZA BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94402-3989
Mailing Address - Country:US
Mailing Address - Phone:650-771-3483
Mailing Address - Fax:
Practice Address - Street 1:211 DE ANZA BLVD
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94402-3989
Practice Address - Country:US
Practice Address - Phone:650-376-3582
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-18
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAKK465558171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty