Provider Demographics
NPI:1033997572
Name:WYNN, KEESHA (CD)
Entity Type:Individual
Prefix:MS
First Name:KEESHA
Middle Name:
Last Name:WYNN
Suffix:
Gender:F
Credentials:CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2795 FIRETHORN AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-1699
Mailing Address - Country:US
Mailing Address - Phone:772-713-1880
Mailing Address - Fax:
Practice Address - Street 1:2795 FIRETHORN AVE FL 32073
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-1699
Practice Address - Country:US
Practice Address - Phone:772-713-1880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-18
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL374J00000X
FLRN9169385163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
No163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant