Healthcare Provider Details

I. General information

NPI: 1871714394
Provider Name (Legal Business Name): PALM BEACH CHILDREN'S ASSOCIATES, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1860 FOREST HILL BLVD STE 102
WEST PALM BEACH FL
33406-6086
US

IV. Provider business mailing address

1860 FOREST HILL BLVD STE 102
WEST PALM BEACH FL
33406-6086
US

V. Phone/Fax

Practice location:
  • Phone: 561-641-6000
  • Fax: 561-641-6006
Mailing address:
  • Phone: 561-641-6000
  • Fax: 561-641-6006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME 0055058
License Number StateFL

VIII. Authorized Official

Name: DR. CONRAD VALENTINO WYNNE JR.
Title or Position: PRESIDENT
Credential: M.D.
Phone: 561-641-6000