Healthcare Provider Details

I. General information

NPI: 1780022749
Provider Name (Legal Business Name): WYNEE LOU D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2013
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 BRICK WALK LN STE 2
FARMINGTON CT
06032-2360
US

IV. Provider business mailing address

16 BRICK WALK LN STE 2
FARMINGTON CT
06032-2360
US

V. Phone/Fax

Practice location:
  • Phone: 860-255-4215
  • Fax: 651-666-1635
Mailing address:
  • Phone: 860-255-4215
  • Fax: 651-666-1635

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number5101023783
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberBP10047614
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number069029
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberR1236
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: