Provider Demographics
NPI:1861157695
Name:WYNN, MARIE (APRN)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:
Last Name:WYNN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 HOUSTON ST
Mailing Address - Street 2:
Mailing Address - City:TIMPSON
Mailing Address - State:TX
Mailing Address - Zip Code:75975-5332
Mailing Address - Country:US
Mailing Address - Phone:940-768-9346
Mailing Address - Fax:
Practice Address - Street 1:1101 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:TX
Practice Address - Zip Code:75766
Practice Address - Country:US
Practice Address - Phone:903-586-0237
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-06
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX935247163WE0003X
TX1140832363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WE0003XNursing Service ProvidersRegistered NurseEmergency