Healthcare Provider Details

I. General information

NPI: 1811774466
Provider Name (Legal Business Name): MICHELLE WYNNE DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2023
Last Update Date: 09/08/2023
Certification Date: 09/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

959 KATIE HAMMOND ST
HANFORD CA
93230-3158
US

IV. Provider business mailing address

1138 W QUAIL ROCK WAY
HANFORD CA
93230-6591
US

V. Phone/Fax

Practice location:
  • Phone: 559-589-7067
  • Fax: 559-589-7015
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number293307
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: