Provider Demographics
NPI:1780864603
Name:WYNN, MARIA ANGELA, CHANDRA (FNP-C)
Entity Type:Individual
Prefix:MISS
First Name:MARIA
Middle Name:ANGELA, CHANDRA
Last Name:WYNN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:MISS
Other - First Name:CHANDRA
Other - Middle Name:
Other - Last Name:WYNN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:5230 VILLAGE WAY
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31907-7492
Mailing Address - Country:US
Mailing Address - Phone:706-905-1127
Mailing Address - Fax:
Practice Address - Street 1:7950 MARTIN LOOP
Practice Address - Street 2:
Practice Address - City:FORT BENNING
Practice Address - State:GA
Practice Address - Zip Code:31905-5647
Practice Address - Country:US
Practice Address - Phone:706-905-1127
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-08
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN180653363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner