Provider Demographics
NPI:1700102530
Name:WYNN, LISA A (LPN)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:A
Last Name:WYNN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 W KEMPER RD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45240-1530
Mailing Address - Country:US
Mailing Address - Phone:513-354-9297
Mailing Address - Fax:
Practice Address - Street 1:1800 W KEMPER RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45240-1530
Practice Address - Country:US
Practice Address - Phone:513-354-9297
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-19
Last Update Date:2010-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN 125206164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse