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General NPI Number Information
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NPI Number | 1861157695
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Entity Type | Individual
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Provider Name | MARIE WYNN APRN
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Gender | Female
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Dates
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Enumeration Date | 11/06/2021
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Last Update Date | 05/21/2024
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Provider Practice Location Address
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Address Line | 1101 COLLEGE AVE
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City | JACKSONVILLE
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State | TX
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Zip | 75766
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Country | US
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Telephone | 903-586-0237
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Fax |
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Provider Business Mailing Address
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Address Line | 620 HOUSTON ST
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City | TIMPSON
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State | TX
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Zip | 75975-5332
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Country | US
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Telephone | 940-768-9346
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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 | 163WE0003X
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Taxonomy Name | Emergency Registered Nurse
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License Number | 935247
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 1140832
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License Number State | TX
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