Provider Demographics
NPI:1245938430
Name:WYNN, DERREIN SHARRON
Entity type:Individual
Prefix:
First Name:DERREIN
Middle Name:SHARRON
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 1:4376 SOUTH 700 EAST
Mailing Address - Street 2:
Mailing Address - City:MILLCREEK
Mailing Address - State:UT
Mailing Address - Zip Code:84107
Mailing Address - Country:US
Mailing Address - Phone:385-272-4292
Mailing Address - Fax:
Practice Address - Street 1:4376 S 700 E
Practice Address - Street 2:
Practice Address - City:MILLCREEK
Practice Address - State:UT
Practice Address - Zip Code:84107-3350
Practice Address - Country:US
Practice Address - Phone:385-272-4292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-17
Last Update Date:2023-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator