Provider Demographics
NPI:1013367218
Name:WYNNE, ANQUONDA
Entity Type:Individual
Prefix:
First Name:ANQUONDA
Middle Name:
Last Name:WYNNE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4425 WINDSOR CT APT 201
Mailing Address - Street 2:
Mailing Address - City:SWARTZ CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:48473-1828
Mailing Address - Country:US
Mailing Address - Phone:810-336-1284
Mailing Address - Fax:
Practice Address - Street 1:4425 WINDSOR CT APT 201
Practice Address - Street 2:
Practice Address - City:SWARTZ CREEK
Practice Address - State:MI
Practice Address - Zip Code:48473-1828
Practice Address - Country:US
Practice Address - Phone:810-336-1284
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-17
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst