Provider Demographics
NPI:1407487077
Name:WYNN, NATALIE RAE (APRN)
Entity Type:Individual
Prefix:
First Name:NATALIE
Middle Name:RAE
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 1:1129 MILPAS LN
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89134-0569
Mailing Address - Country:US
Mailing Address - Phone:702-969-4355
Mailing Address - Fax:
Practice Address - Street 1:3841 W CHARLESTON BLVD STE 203
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-1858
Practice Address - Country:US
Practice Address - Phone:702-848-4443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-31
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV815950363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner