Provider Demographics
NPI:1568471001
Name:SUSAN P. WYNNE, PLLC
Entity Type:Organization
Organization Name:SUSAN P. WYNNE, PLLC
Other - Org Name:EASTSIDE VISION CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WYNNE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:425-882-2923
Mailing Address - Street 1:8309 165TH AVE NE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:REDMOND
Mailing Address - State:WA
Mailing Address - Zip Code:98052-3939
Mailing Address - Country:US
Mailing Address - Phone:425-882-2923
Mailing Address - Fax:
Practice Address - Street 1:8309 165TH AVE NE
Practice Address - Street 2:SUITE 102
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98052-3939
Practice Address - Country:US
Practice Address - Phone:425-882-2923
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA3012152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty