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General NPI Number Information
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NPI Number | 1083012561
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Entity Type | Individual
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Provider Name | BEVERLY WYNNE APRN
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Gender | Female
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Dates
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Enumeration Date | 12/15/2014
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Last Update Date | 12/15/2014
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Provider Practice Location Address
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Address Line | 677 CHURCH ST NE
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City | MARIETTA
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State | GA
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Zip | 30060-1101
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Country | US
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Telephone | 770-792-9808
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Fax |
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Provider Business Mailing Address
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Address Line | 4120 BRIGADE TRL NW
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City | KENNESAW
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State | GA
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Zip | 30152-7722
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Country | US
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Telephone | 770-424-6172
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LN0005X
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Taxonomy Name | Critical Care Neonatal Nurse Practitioner
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License Number | RN079004
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License Number State | GA
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