Provider Demographics
NPI:1952188179
Name:WYNNE, TANNER RYAN
Entity Type:Individual
Prefix:
First Name:TANNER
Middle Name:RYAN
Last Name:WYNNE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316 WINNOW DR
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:DE
Mailing Address - Zip Code:19938-3531
Mailing Address - Country:US
Mailing Address - Phone:302-922-4090
Mailing Address - Fax:
Practice Address - Street 1:316 WINNOW DR
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:DE
Practice Address - Zip Code:19938-3531
Practice Address - Country:US
Practice Address - Phone:302-922-4090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-11
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer