Provider Demographics
NPI:1346422615
Name:WYNNE, MARISA MARIE (DO)
Entity Type:Individual
Prefix:DR
First Name:MARISA
Middle Name:MARIE
Last Name:WYNNE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:MARISA
Other - Middle Name:MARIE
Other - Last Name:GATES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:1934 NILES CORTLAND RD NE STE B
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44484-1055
Mailing Address - Country:US
Mailing Address - Phone:330-841-4032
Mailing Address - Fax:330-841-4381
Practice Address - Street 1:1934 NILES CORTLAND RD NE STE B
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44484-1055
Practice Address - Country:US
Practice Address - Phone:330-841-4032
Practice Address - Fax:330-841-4381
Is Sole Proprietor?:No
Enumeration Date:2007-11-28
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.009421207L00000X, 208VP0014X, 208VP0000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0082233Medicaid