Provider Demographics
NPI:1538338835
Name:WANNER, LYNNETT M (LSW)
Entity type:Individual
Prefix:
First Name:LYNNETT
Middle Name:M
Last Name:WANNER
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1237 W DIVIDE AVE
Mailing Address - Street 2:STE 5
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-1208
Mailing Address - Country:US
Mailing Address - Phone:701-328-8895
Mailing Address - Fax:701-328-8900
Practice Address - Street 1:1237 W DIVIDE AVE
Practice Address - Street 2:STE 5
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-1208
Practice Address - Country:US
Practice Address - Phone:701-328-8895
Practice Address - Fax:701-328-8900
Is Sole Proprietor?:No
Enumeration Date:2008-02-21
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND3305104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker