Healthcare Provider Details

I. General information

NPI: 1053377549
Provider Name (Legal Business Name): CHARLOTTE CASEY WYNN CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2006
Last Update Date: 09/09/2020
Certification Date: 09/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9900 BREN RD E
MINNETONKA MN
55343-9664
US

IV. Provider business mailing address

1735 KESTWICK CIR
HOOVER AL
35226-2347
US

V. Phone/Fax

Practice location:
  • Phone: 334-272-9684
  • Fax:
Mailing address:
  • Phone: 334-782-2642
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1-040730
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: