Provider Demographics
NPI:1619044161
Name:TYNES-MCCRAY, WANDA JUNE (FNP)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:JUNE
Last Name:TYNES-MCCRAY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 N MAIN ST STE 200
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-4564
Mailing Address - Country:US
Mailing Address - Phone:757-983-8600
Mailing Address - Fax:757-934-3012
Practice Address - Street 1:114 N MAIN ST STE 200
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-4564
Practice Address - Country:US
Practice Address - Phone:757-983-8600
Practice Address - Fax:757-934-3012
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024100542363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner