Provider Demographics
NPI:1942061866
Name:WYNNE, TINA M (MEDICAL MASSAGE PRAC)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:M
Last Name:WYNNE
Suffix:
Gender:F
Credentials:MEDICAL MASSAGE PRAC
Other - Prefix:MISS
Other - First Name:TINA
Other - Middle Name:
Other - Last Name:ANZALONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MASSAGE THERAPY
Mailing Address - Street 1:5231 WOODCOCK RD
Mailing Address - Street 2:
Mailing Address - City:SEQUIM
Mailing Address - State:WA
Mailing Address - Zip Code:98382-8524
Mailing Address - Country:US
Mailing Address - Phone:702-236-4313
Mailing Address - Fax:
Practice Address - Street 1:625 N 5TH AVE STE 4
Practice Address - Street 2:
Practice Address - City:SEQUIM
Practice Address - State:WA
Practice Address - Zip Code:98382-5062
Practice Address - Country:US
Practice Address - Phone:702-236-4313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-18
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA61492260225700000X
WA61492260225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist