=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093746463
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EMILY ROSE WYNN MN, APRN, BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/05/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | PHOEBE PUTNEY MEMORIAL HOSPITAL 417 THIRD AVE, SUITE 300
-----------------------------------------------------
City | ALBANY
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31702-1828
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-312-0300
-----------------------------------------------------
Fax | 229-312-0295
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2604 E DOUBLEGATE DR
-----------------------------------------------------
City | ALBANY
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31721-9243
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-888-6235
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | RN159433
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------