Provider Demographics
NPI:1265269815
Name:WYNNE, LINDA M (LMT)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:M
Last Name:WYNNE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 SW 5TH ST STE B
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-2509
Mailing Address - Country:US
Mailing Address - Phone:541-471-0397
Mailing Address - Fax:
Practice Address - Street 1:333 SW 5TH ST STE B
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-2509
Practice Address - Country:US
Practice Address - Phone:541-471-0397
Practice Address - Fax:541-471-6459
Is Sole Proprietor?:No
Enumeration Date:2024-09-17
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR28446225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist