Provider Demographics
NPI:1790366011
Name:WYNN, LINDA ELIZABETH
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:ELIZABETH
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 1:1155 W STATE ROAD 434 SUITE 115
Mailing Address - Street 2:# 294
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750
Mailing Address - Country:US
Mailing Address - Phone:864-523-3001
Mailing Address - Fax:
Practice Address - Street 1:1198 LAKE LUCERNE CIR
Practice Address - Street 2:
Practice Address - City:WINTER SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32708-2333
Practice Address - Country:US
Practice Address - Phone:864-523-3001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-19
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376J00000XNursing Service Related ProvidersHomemaker
No372500000XNursing Service Related ProvidersChore Provider
No372600000XNursing Service Related ProvidersAdult CompanionGroup - Single Specialty