Healthcare Provider Details

I. General information

NPI: 1003278029
Provider Name (Legal Business Name): LYNNEA WILSON MORM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LYNNEA ELIZABETH WILSON

II. Dates (important events)

Enumeration Date: 03/28/2016
Last Update Date: 01/07/2020
Certification Date: 01/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1403 LOMITA BLVD STE 102
HARBOR CITY CA
90710-2084
US

IV. Provider business mailing address

1403 LOMITA BLVD STE 102
HARBOR CITY CA
90710-2084
US

V. Phone/Fax

Practice location:
  • Phone: 310-534-7600
  • Fax:
Mailing address:
  • Phone: 310-534-7600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A15880
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: