Healthcare Provider Details

I. General information

NPI: 1457135899
Provider Name (Legal Business Name): MAKAYLA MARIE WYNN APRN, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MAKAYLA MARIE WISENBAKER RN

II. Dates (important events)

Enumeration Date: 08/24/2023
Last Update Date: 03/21/2024
Certification Date: 03/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

711 ONYX ST
KEMMERER WY
83101-3214
US

IV. Provider business mailing address

419 LARAMIE ST
EVANSTON WY
82930-9104
US

V. Phone/Fax

Practice location:
  • Phone: 307-877-4401
  • Fax: 307-877-9769
Mailing address:
  • Phone: 307-679-5287
  • Fax: 307-877-3236

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number52717
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: