Provider Demographics
NPI:1588312144
Name:WYNNE, MIRANDA ANNE (LMT)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:ANNE
Last Name:WYNNE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:MIRANDA
Other - Middle Name:ANNE
Other - Last Name:CZYZYK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:258 KINGS HWY E
Mailing Address - Street 2:
Mailing Address - City:HADDONFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:08033-1907
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:258 KINGS HWY E
Practice Address - Street 2:
Practice Address - City:HADDONFIELD
Practice Address - State:NJ
Practice Address - Zip Code:08033-1907
Practice Address - Country:US
Practice Address - Phone:248-565-6561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-14
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist