MEDICARE: BRENDA WHITE WYNN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT000648	GA

General Provider Information

NPI Number	:	1952604514
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRENDA WHITE WYNN

Provider Business Mailing Address
First Line	:	2582 ROLLING BROOK TRL
Second Line	:
City	:	EAST POINT
State	:	GA
Zip	:	30344-4008
Country	:	US
Telephone Number	:	404-669-0271
Fax Number	:

Provider Business Practice Location Address
First Line	:	2582 ROLLING BROOK TRL
Second Line	:
City	:	EAST POINT
State	:	GA
Zip	:	30344-4008
Country	:	US
Telephone Number	:	404-669-0271
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/20/2010
Last Update Date	:	12/20/2010

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Directions to “ BRENDA WHITE WYNN ” Practice Location

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