Provider Demographics
NPI:1467902478
Name:WYNN, KERRIE MINCE (FNP-BC)
Entity Type:Individual
Prefix:
First Name:KERRIE
Middle Name:MINCE
Last Name:WYNN
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:KERRIE
Other - Middle Name:JANE
Other - Last Name:MINCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:23800 JOHN T REID PARKWAY
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBORO
Mailing Address - State:AL
Mailing Address - Zip Code:35768
Mailing Address - Country:US
Mailing Address - Phone:256-999-0808
Mailing Address - Fax:844-490-5875
Practice Address - Street 1:23800 JOHN T REID PKWY
Practice Address - Street 2:
Practice Address - City:SCOTTSBORO
Practice Address - State:AL
Practice Address - Zip Code:35768-2841
Practice Address - Country:US
Practice Address - Phone:256-999-0808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-13
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-115555363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1-115555OtherRN LICENSE
2016002419OtherANCC