Provider Demographics
NPI:1407245657
Name:WYNN, CAMILLE ANN (LMP)
Entity Type:Individual
Prefix:MS
First Name:CAMILLE
Middle Name:ANN
Last Name:WYNN
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 488
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-0074
Mailing Address - Country:US
Mailing Address - Phone:360-460-6140
Mailing Address - Fax:
Practice Address - Street 1:25 SHORT RD
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-8189
Practice Address - Country:US
Practice Address - Phone:360-460-6140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-12
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60524213225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist