Provider Demographics
NPI:1518626092
Name:DUONG, WYNNE (AGACNP-BC)
Entity Type:Individual
Prefix:
First Name:WYNNE
Middle Name:
Last Name:DUONG
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2761 IROQUOIS RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38111-2015
Mailing Address - Country:US
Mailing Address - Phone:615-424-5412
Mailing Address - Fax:
Practice Address - Street 1:80 HUMPHREYS CENTER DR STE 106
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2352
Practice Address - Country:US
Practice Address - Phone:901-455-7440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-13
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN186324163W00000X
TN30352363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse