Healthcare Provider Details

I. General information

NPI: 1871424606
Provider Name (Legal Business Name): ANDREA LEIGH WYNN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2026
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1549 S SAINT FRANCIS DR
SANTA FE NM
87505-4039
US

IV. Provider business mailing address

6857 NACELLE RD NE
RIO RANCHO NM
87144-3527
US

V. Phone/Fax

Practice location:
  • Phone: 505-820-9970
  • Fax:
Mailing address:
  • Phone: 785-404-7289
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number83240
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: