Provider Demographics
NPI:1326414970
Name:WYNNE, KATHERINE LOUISE
Entity Type:Individual
Prefix:MISS
First Name:KATHERINE
Middle Name:LOUISE
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 1:110 FONTAINBLEAU DR
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70471-6419
Mailing Address - Country:US
Mailing Address - Phone:504-458-4315
Mailing Address - Fax:
Practice Address - Street 1:110 FONTAINBLEAU DR
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70471-6419
Practice Address - Country:US
Practice Address - Phone:504-458-4315
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-18
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program