Healthcare Provider Details

I. General information

NPI: 1922431063
Provider Name (Legal Business Name): BRENDAN PATRICK WYNNE D.N.P.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2013
Last Update Date: 09/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 MALL RD LAHEY CLINIC
BURLINGTON MA
01805-0001
US

IV. Provider business mailing address

41 MALL RD LAHEY CLINIC
BURLINGTON MA
01805-0001
US

V. Phone/Fax

Practice location:
  • Phone: 781-744-1286
  • Fax:
Mailing address:
  • Phone: 781-744-8013
  • Fax: 781-744-5235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number260469
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number260469
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: