Provider Demographics
NPI:1356305478
Name:WYNN, SHARON SCHROEDER (MD)
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:SCHROEDER
Last Name:WYNN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SHARON
Other - Middle Name:LYNN
Other - Last Name:SCHROEDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:7409 US 42
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:KY
Mailing Address - Zip Code:41042-1905
Mailing Address - Country:US
Mailing Address - Phone:859-525-8181
Mailing Address - Fax:859-525-8289
Practice Address - Street 1:7409 US 42
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042-1905
Practice Address - Country:US
Practice Address - Phone:859-525-8181
Practice Address - Fax:859-525-8289
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2014-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY305842080A0000X, 2084P0804X
OH35 075729208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY184607OtherMEDICARE GROUP NUMBER
KY65932758Medicaid
311542435OtherFEDERAL TAX ID