Provider Demographics
NPI:1104105451
Name:WYNNE, MELVIN (HUMAN SERVICE)
Entity type:Individual
Prefix:
First Name:MELVIN
Middle Name:
Last Name:WYNNE
Suffix:
Gender:M
Credentials:HUMAN SERVICE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:970 E 100TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-4014
Mailing Address - Country:US
Mailing Address - Phone:347-589-7246
Mailing Address - Fax:347-405-8894
Practice Address - Street 1:970 E 100TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11236-4014
Practice Address - Country:US
Practice Address - Phone:347-589-7246
Practice Address - Fax:347-405-8894
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-04
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY197829188347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle