Healthcare Provider Details

I. General information

NPI: 1255250437
Provider Name (Legal Business Name): MARISSA NINA WYNN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2026
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7439 FRANKFORD AVE LOWR LEVEL2
PHILADELPHIA PA
19136-3600
US

IV. Provider business mailing address

7439 FRANKFORD AVE LOWR LEVEL2
PHILADELPHIA PA
19136-3600
US

V. Phone/Fax

Practice location:
  • Phone: 267-689-7877
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: