Provider Demographics
NPI:1093138083
Name:WYNN, ARACELIS (APRN)
Entity Type:Individual
Prefix:
First Name:ARACELIS
Middle Name:
Last Name:WYNN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1608 SE 3RD AVENUE
Mailing Address - Street 2:THIRD FLOOR PBO
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33316-2564
Mailing Address - Country:US
Mailing Address - Phone:954-320-3323
Mailing Address - Fax:954-753-6377
Practice Address - Street 1:1751 BONAVENTURE BLVD
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33326-4039
Practice Address - Country:US
Practice Address - Phone:954-385-0014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-27
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9235724363LF0000X
FLAPRN9235724363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL013225500Medicaid