=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649026923
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DESTINY WYNN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/26/2024
-----------------------------------------------------
Last Update Date | 04/26/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2313 W ARKANSAS LN STE 103
-----------------------------------------------------
City | PANTEGO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76013-6034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-249-1355
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 355 LAS COLINAS BLVD E APT 317
-----------------------------------------------------
City | IRVING
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75039-6247
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-574-6032
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------