Provider Demographics
NPI:1265885594
Name:WYNHAUSEN, ALEXIS (LAC)
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:
Last Name:WYNHAUSEN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 LEAVENWORTH ST APT 605
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94109-6161
Mailing Address - Country:US
Mailing Address - Phone:151-091-0341
Mailing Address - Fax:925-945-8691
Practice Address - Street 1:1800 OAK PARK BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:PLEASANT HILL
Practice Address - State:CA
Practice Address - Zip Code:94523-4479
Practice Address - Country:US
Practice Address - Phone:925-945-7890
Practice Address - Fax:925-945-8691
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-21
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16493171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist