Provider Demographics
NPI:1710245691
Name:WYNNE, AMY SIMMONS (NP)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:SIMMONS
Last Name:WYNNE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2666
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70404-2666
Mailing Address - Country:US
Mailing Address - Phone:985-230-3066
Mailing Address - Fax:985-230-2072
Practice Address - Street 1:15790 PAUL VEGA MD DR
Practice Address - Street 2:HOSPITAL MEDICINE PROGRAM
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403-1434
Practice Address - Country:US
Practice Address - Phone:985-230-3066
Practice Address - Fax:985-230-2072
Is Sole Proprietor?:No
Enumeration Date:2012-04-27
Last Update Date:2017-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP06816363LA2100X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2191462Medicaid
LA2191462Medicaid