Provider Demographics
NPI:1093198202
Name:WYN, JANICE LEE
Entity Type:Individual
Prefix:
First Name:JANICE
Middle Name:LEE
Last Name:WYN
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 1:4313 MONROE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-2062
Mailing Address - Country:US
Mailing Address - Phone:269-532-3281
Mailing Address - Fax:
Practice Address - Street 1:4313 MONROE AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-2062
Practice Address - Country:US
Practice Address - Phone:269-532-3281
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-07
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0156818171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator