Healthcare Provider Details

I. General information

NPI: 1316197023
Provider Name (Legal Business Name): JULIA ELIZABETH WYNNE L.AC.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2008
Last Update Date: 09/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2560 1ST AVE STE 202
SAN DIEGO CA
92103-6575
US

IV. Provider business mailing address

2560 1ST AVE STE 202
SAN DIEGO CA
92103-6575
US

V. Phone/Fax

Practice location:
  • Phone: 619-251-1925
  • Fax:
Mailing address:
  • Phone: 619-251-1925
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC6126
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: