Healthcare Provider Details

I. General information

NPI: 1669791125
Provider Name (Legal Business Name): PROF. BREANNA J WYNN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2010
Last Update Date: 05/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1430 OLIVE ST STE. 500
SAINT LOUIS MO
63103-2303
US

IV. Provider business mailing address

1430 OLIVE ST STE. 500
SAINT LOUIS MO
63103-2303
US

V. Phone/Fax

Practice location:
  • Phone: 314-206-3700
  • Fax: 314-206-3708
Mailing address:
  • Phone: 314-206-3700
  • Fax: 314-206-3708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: