Provider Demographics
NPI:1003278029
Name:MORM, LYNNEA WILSON
Entity Type:Individual
Prefix:
First Name:LYNNEA
Middle Name:WILSON
Last Name:MORM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LYNNEA
Other - Middle Name:ELIZABETH
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1403 LOMITA BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:HARBOR CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90710-2084
Mailing Address - Country:US
Mailing Address - Phone:310-534-7600
Mailing Address - Fax:
Practice Address - Street 1:1403 LOMITA BLVD STE 102
Practice Address - Street 2:
Practice Address - City:HARBOR CITY
Practice Address - State:CA
Practice Address - Zip Code:90710-2084
Practice Address - Country:US
Practice Address - Phone:310-534-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-28
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A15880207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine