Provider Demographics
NPI:1063806172
Name:WYMORE, SUZANNA
Entity type:Individual
Prefix:
First Name:SUZANNA
Middle Name:
Last Name:WYMORE
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 1:1644 SEASHELL LN
Mailing Address - Street 2:
Mailing Address - City:WACONIA
Mailing Address - State:MN
Mailing Address - Zip Code:55387-1054
Mailing Address - Country:US
Mailing Address - Phone:952-452-6519
Mailing Address - Fax:
Practice Address - Street 1:1644 SEASHELL LN
Practice Address - Street 2:
Practice Address - City:WACONIA
Practice Address - State:MN
Practice Address - Zip Code:55387-1054
Practice Address - Country:US
Practice Address - Phone:952-452-6519
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-26
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer