Provider Demographics
NPI:1215315403
Name:WYNNE, THALIA
Entity type:Individual
Prefix:
First Name:THALIA
Middle Name:
Last Name:WYNNE
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 1:6814 GREELEY AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45424-1794
Mailing Address - Country:US
Mailing Address - Phone:605-431-5364
Mailing Address - Fax:
Practice Address - Street 1:6814 GREELEY AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45424-1794
Practice Address - Country:US
Practice Address - Phone:605-431-5364
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-08
Last Update Date:2015-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2255A2300X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer