Provider Demographics
NPI:1841232972
Name:WYNNE, JOELLEN (FNP)
Entity Type:Individual
Prefix:
First Name:JOELLEN
Middle Name:
Last Name:WYNNE
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 1:1881 NW 185TH AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:ALOHA
Mailing Address - State:OR
Mailing Address - Zip Code:97006-6822
Mailing Address - Country:US
Mailing Address - Phone:503-439-1539
Mailing Address - Fax:
Practice Address - Street 1:1705 CLOVERLEAF DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78723-3425
Practice Address - Country:US
Practice Address - Phone:512-507-9525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR240328Medicaid
ORR116559Medicare ID - Type UnspecifiedGROUP
ORR116560Medicare ID - Type UnspecifiedINDIVIDUAL
OR240328Medicaid