MEDICARE: AMBER WYNN

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	174400000X	Specialist

General Provider Information

NPI Number	:	1215771704
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMBER WYNN

Provider Business Mailing Address
First Line	:	1701 RIVER RUN STE 302
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76107-6547
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1701 RIVER RUN STE 302
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76107-6547
Country	:	US
Telephone Number	:	512-884-5190
Fax Number	:

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

Provider Enumeration Date	:	06/20/2024
Last Update Date	:	06/20/2024

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Directions to “ AMBER WYNN ” Practice Location

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