Healthcare Provider Details

I. General information

NPI: 1093882664
Provider Name (Legal Business Name): MICHELLE HEWLETT WYNN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 07/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8401 MEDICAL PLAZA DR STE 300
CHARLOTTE NC
28262-8702
US

IV. Provider business mailing address

8401 MEDICAL PLAZA DR STE 300
CHARLOTTE NC
28262-8702
US

V. Phone/Fax

Practice location:
  • Phone: 704-316-6561
  • Fax: 704-384-1977
Mailing address:
  • Phone: 704-316-6573
  • Fax: 704-384-1977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number928407
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: