Provider Demographics
NPI:1417099656
Name:WYNNE, LISA (ARNP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:WYNNE
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 SW 62ND AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-3009
Mailing Address - Country:US
Mailing Address - Phone:786-624-2636
Mailing Address - Fax:305-668-5595
Practice Address - Street 1:3100 SW 62ND AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-3009
Practice Address - Country:US
Practice Address - Phone:786-624-2636
Practice Address - Fax:305-668-5595
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1750482363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL027923400OtherLINKED TO MDC HEALTH DEPT
FLP01436Medicare UPIN
FLE3756ZMedicare ID - Type UnspecifiedPROVIDER NUMBER
FL300689100Medicaid