Provider Demographics
NPI:1093746463
Name:WYNN, EMILY ROSE (MN, APRN, BC)
Entity Type:Individual
Prefix:MS
First Name:EMILY
Middle Name:ROSE
Last Name:WYNN
Suffix:
Gender:F
Credentials:MN, APRN, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2604 E DOUBLEGATE DR
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31721-9243
Mailing Address - Country:US
Mailing Address - Phone:229-888-6235
Mailing Address - Fax:
Practice Address - Street 1:PHOEBE PUTNEY MEMORIAL HOSPITAL
Practice Address - Street 2:417 THIRD AVE, SUITE 300
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31702-1828
Practice Address - Country:US
Practice Address - Phone:229-312-0300
Practice Address - Fax:229-312-0295
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN159433363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily