Provider Demographics
NPI:1730766130
Name:WYNN, LAURI (WYNN DRIVING SERVICE)
Entity type:Individual
Prefix:
First Name:LAURI
Middle Name:
Last Name:WYNN
Suffix:
Gender:F
Credentials:WYNN DRIVING SERVICE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28609 N PORT LN
Mailing Address - Street 2:
Mailing Address - City:MENIFEE
Mailing Address - State:CA
Mailing Address - Zip Code:92584-8169
Mailing Address - Country:US
Mailing Address - Phone:909-921-3193
Mailing Address - Fax:
Practice Address - Street 1:28609 N PORT LN
Practice Address - Street 2:
Practice Address - City:MENIFEE
Practice Address - State:CA
Practice Address - Zip Code:92584-8169
Practice Address - Country:US
Practice Address - Phone:909-921-3193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-24
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA3123559172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver