Healthcare Provider Details

I. General information

NPI: 1124559455
Provider Name (Legal Business Name): BRIANNA WYNNE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2017
Last Update Date: 09/01/2023
Certification Date: 09/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 BENMORE DR STE 200
WINTER PARK FL
32792-4111
US

IV. Provider business mailing address

133 BENMORE DR STE 200
WINTER PARK FL
32792-4111
US

V. Phone/Fax

Practice location:
  • Phone: 407-599-6060
  • Fax: 407-646-7747
Mailing address:
  • Phone: 407-599-6060
  • Fax: 407-646-7747

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME147648
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberME147648
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: