Healthcare Provider Details

I. General information

NPI: 1194234252
Provider Name (Legal Business Name): MELISSA A WYNNE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2017
Last Update Date: 01/13/2020
Certification Date: 01/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

512 NW 9TH ST
DELRAY BEACH FL
33444-2836
US

IV. Provider business mailing address

512 NW 9TH ST
DELRAY BEACH FL
33444-2836
US

V. Phone/Fax

Practice location:
  • Phone: 845-705-3777
  • Fax:
Mailing address:
  • Phone: 845-705-3777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN2299860
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number11004240
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: