MEDICARE: MRS. LISA A WYNN LPN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	PN 125206	OH

General Provider Information

NPI Number	:	1700102530
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LISA A WYNN LPN

Provider Business Mailing Address
First Line	:	1800 W KEMPER RD
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45240-1530
Country	:	US
Telephone Number	:	513-354-9297
Fax Number	:

Provider Business Practice Location Address
First Line	:	1800 W KEMPER RD
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45240-1530
Country	:	US
Telephone Number	:	513-354-9297
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/19/2010
Last Update Date	:	04/19/2010

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