=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356493084
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOELLEN WYNNE, FNP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1705 CLOVERLEAF DR
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78723-3425
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-507-9525
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1705 CLOVERLEAF DR
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78723-3425
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JOELLEN WYNNE
-----------------------------------------------------
Credential | FNP
-----------------------------------------------------
Telephone | 512-507-9525
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------