Provider Demographics
NPI:1851062137
Name:WYNN, ASHLEY
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:WYNN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:317 RIVER RD N
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-3531
Mailing Address - Country:US
Mailing Address - Phone:601-850-7248
Mailing Address - Fax:
Practice Address - Street 1:317 RIVER RD N
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-3531
Practice Address - Country:US
Practice Address - Phone:601-850-7248
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-25
Last Update Date:2021-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide