Provider Demographics
NPI:1568699619
Name:WYNN, NICOLE M
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:M
Last Name:WYNN
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 1:8362 SASSAFRAS RD
Mailing Address - Street 2:
Mailing Address - City:DU QUOIN
Mailing Address - State:IL
Mailing Address - Zip Code:62832-3604
Mailing Address - Country:US
Mailing Address - Phone:618-542-4234
Mailing Address - Fax:
Practice Address - Street 1:8362 SASSAFRAS RD
Practice Address - Street 2:
Practice Address - City:DU QUOIN
Practice Address - State:IL
Practice Address - Zip Code:62832-3604
Practice Address - Country:US
Practice Address - Phone:618-542-4234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-16
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist