Provider Demographics
NPI:1548591704
Name:WYNEKEN, GINA M (LAC, LMP)
Entity Type:Individual
Prefix:MS
First Name:GINA
Middle Name:M
Last Name:WYNEKEN
Suffix:
Gender:F
Credentials:LAC, LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2244 BARTON AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-3408
Mailing Address - Country:US
Mailing Address - Phone:530-494-0900
Mailing Address - Fax:
Practice Address - Street 1:2244 BARTON AVE
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-3408
Practice Address - Country:US
Practice Address - Phone:530-494-0900
Practice Address - Fax:530-494-0900
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-27
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 13270171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist