Provider Demographics
NPI:1164967105
Name:WYNNE, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:WYNNE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92 LITCHFIELD LN
Mailing Address - Street 2:
Mailing Address - City:HANSON
Mailing Address - State:MA
Mailing Address - Zip Code:02341-1011
Mailing Address - Country:US
Mailing Address - Phone:781-724-2201
Mailing Address - Fax:
Practice Address - Street 1:120 MURRAY ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-1300
Practice Address - Country:US
Practice Address - Phone:781-391-0800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-29
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA390200000XMedicaid
MA390200000XMedicare PIN
MA390200000XMedicaid
MA390200000XMedicare Oscar/Certification