Provider Demographics
NPI:1831790898
Name:WYNVEEN, TRESA
Entity type:Individual
Prefix:
First Name:TRESA
Middle Name:
Last Name:WYNVEEN
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:N3299 TIPPERARY RD
Mailing Address - Street 2:
Mailing Address - City:CASCADE
Mailing Address - State:WI
Mailing Address - Zip Code:53011-1512
Mailing Address - Country:US
Mailing Address - Phone:920-838-1704
Mailing Address - Fax:
Practice Address - Street 1:3711 S TAYLOR DR
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-8495
Practice Address - Country:US
Practice Address - Phone:920-459-8601
Practice Address - Fax:920-459-8662
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-05
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12116-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist