Provider Demographics
NPI:1154102424
Name:WYNN, MELISSA LORRAINE (CMT)
Entity type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:LORRAINE
Last Name:WYNN
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 720591
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95172-0591
Mailing Address - Country:US
Mailing Address - Phone:408-608-7909
Mailing Address - Fax:
Practice Address - Street 1:1449 SHORTRIDGE AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95116-2351
Practice Address - Country:US
Practice Address - Phone:408-608-7909
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-11
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA73052225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist