Provider Demographics
NPI:1124471958
Name:WYNN, CLINTON CHARLES
Entity type:Individual
Prefix:
First Name:CLINTON
Middle Name:CHARLES
Last Name:WYNN
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 1:5722 BISCAYNE CT # CONDO108
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34652-2031
Mailing Address - Country:US
Mailing Address - Phone:727-534-4755
Mailing Address - Fax:727-843-0401
Practice Address - Street 1:5722 BISCAYNE CT # CONDO108
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34652-2031
Practice Address - Country:US
Practice Address - Phone:727-534-4755
Practice Address - Fax:727-843-0401
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-17
Last Update Date:2016-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL13372255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer