Provider Demographics
NPI:1689340291
Name:WYNN, SHANNON (DPT)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:WYNN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9500 W MAULE AVE UNIT 2029
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-4279
Mailing Address - Country:US
Mailing Address - Phone:702-556-1163
Mailing Address - Fax:
Practice Address - Street 1:2820 W CHARLESTON BLVD STE 1
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-1942
Practice Address - Country:US
Practice Address - Phone:725-726-7847
Practice Address - Fax:725-726-7876
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-23
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV4642225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist