Provider Demographics
NPI:1952624884
Name:WAGNER, LYNETTE ANN (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:LYNETTE
Middle Name:ANN
Last Name:WAGNER
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:MISS
Other - First Name:LYNETTE
Other - Middle Name:ANN
Other - Last Name:LUKOMSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR/L
Mailing Address - Street 1:5774 GARNET CIR
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48348-3060
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5774 GARNET CIR
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48348-3060
Practice Address - Country:US
Practice Address - Phone:586-242-6541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-06
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201006848171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor