Provider Demographics
NPI:1629568894
Name:WYNNE, SHAKEERA
Entity Type:Individual
Prefix:
First Name:SHAKEERA
Middle Name:
Last Name:WYNNE
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 1:33 S 9TH STREET
Mailing Address - Street 2:SUITE 220
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107
Mailing Address - Country:US
Mailing Address - Phone:215-503-8845
Mailing Address - Fax:152-503-3835
Practice Address - Street 1:33 S 9TH STREET
Practice Address - Street 2:SUITE 220
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107
Practice Address - Country:US
Practice Address - Phone:215-503-8845
Practice Address - Fax:215-503-3835
Is Sole Proprietor?:No
Enumeration Date:2018-05-14
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1024869940001Medicaid