Provider Demographics
NPI:1033529524
Name:WYNN, TERRIE L (LPN)
Entity Type:Individual
Prefix:
First Name:TERRIE
Middle Name:L
Last Name:WYNN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:TERRIE
Other - Middle Name:L
Other - Last Name:FOSTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2202 E 48TH ST.
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-1214
Mailing Address - Country:US
Mailing Address - Phone:563-343-1810
Mailing Address - Fax:563-326-1901
Practice Address - Street 1:2202 E 48TH ST.
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-1214
Practice Address - Country:US
Practice Address - Phone:563-343-1810
Practice Address - Fax:563-326-1901
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-06
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY220930164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse