Basic Information
| Provider Information | |||||||||
| NPI: | 1316254709 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WYNN | ||||||||
| FirstName: | ANITA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | C.R.N.A. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WYNN | ||||||||
| OtherFirstName: | LYN | ||||||||
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| OtherCredential: | C.R.N.A. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 620 SKYLINE DRIVE | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 38301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7315417070 | ||||||||
| FaxNumber: | 7315417075 | ||||||||
| Practice Location | |||||||||
| Address1: | 620 SKYLINE DRIVE | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 38301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7315417070 | ||||||||
| FaxNumber: | 7315417075 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2010 | ||||||||
| LastUpdateDate: | 07/19/2018 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | APN15193 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 163W00000X | RN163107 | TN | N | Nursing Service Providers | Registered Nurse |
No ID Information.