Healthcare Provider Details

I. General information

NPI: 1710967740
Provider Name (Legal Business Name): MARY L WYNN-JOHNSON CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2006
Last Update Date: 11/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8140 N MOPAC EXPY STE 3-210
AUSTIN TX
78759-8859
US

IV. Provider business mailing address

19535 SANDCASTLE DR
SPICEWOOD TX
78669-6702
US

V. Phone/Fax

Practice location:
  • Phone: 512-493-9237
  • Fax:
Mailing address:
  • Phone: 512-599-5280
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP137379
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: