Provider Demographics
NPI:1710534607
Name:WYNNE, KAITLYN (FNP-C)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:
Last Name:WYNNE
Suffix:
Gender:F
Credentials:FNP-C
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 3046
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:PA
Mailing Address - Zip Code:19355-0746
Mailing Address - Country:US
Mailing Address - Phone:806-452-5522
Mailing Address - Fax:806-452-3070
Practice Address - Street 1:301 N 23RD ST STE C
Practice Address - Street 2:
Practice Address - City:CANYON
Practice Address - State:TX
Practice Address - Zip Code:79015-3058
Practice Address - Country:US
Practice Address - Phone:806-452-5522
Practice Address - Fax:806-452-3070
Is Sole Proprietor?:No
Enumeration Date:2019-08-25
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP142425363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily