Provider Demographics
NPI:1063608594
Name:WYNN, DOMINIQUE E (DPT)
Entity type:Individual
Prefix:DR
First Name:DOMINIQUE
Middle Name:E
Last Name:WYNN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:375 MACARTHUR AVE
Mailing Address - Street 2:# 2
Mailing Address - City:LONG BRANCH
Mailing Address - State:NJ
Mailing Address - Zip Code:07740-7649
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:375 MACARTHUR AVE
Practice Address - Street 2:# 2
Practice Address - City:LONG BRANCH
Practice Address - State:NJ
Practice Address - Zip Code:07740-7649
Practice Address - Country:US
Practice Address - Phone:415-846-0395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-19
Last Update Date:2019-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25685225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist