Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | DH87919 | MA |
NPI | 1043566433 |
---|---|
Provider Name | Tamra Rae Wynn |
First Address | Lynn, MA 01901-1314 |
Second Address | Lynn, MA 01901-1314 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/08/2012 |
Last Update Date | 03/08/2012 |