Healthcare Provider Details

I. General information

NPI: 1427588219
Provider Name (Legal Business Name): CAITLIN WUNNER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2017
Last Update Date: 06/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 COAL ST
WILKES BARRE PA
18702-6626
US

IV. Provider business mailing address

460 SCOTT ST APT 2
WILKES BARRE PA
18702-5552
US

V. Phone/Fax

Practice location:
  • Phone: 570-793-1695
  • Fax:
Mailing address:
  • Phone: 570-262-2781
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMSG011052
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: