Provider Demographics
NPI:1295065688
Name:WYNN, LISA ANN (APRN)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ANN
Last Name:WYNN
Suffix:
Gender:
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:334 CORINTH CHURCH DR
Mailing Address - Street 2:
Mailing Address - City:JONESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24263-7992
Mailing Address - Country:US
Mailing Address - Phone:606-795-7533
Mailing Address - Fax:
Practice Address - Street 1:41718 W MORGAN AVE STE 101
Practice Address - Street 2:
Practice Address - City:PENNINGTON GAP
Practice Address - State:VA
Practice Address - Zip Code:24277-3224
Practice Address - Country:US
Practice Address - Phone:276-231-9228
Practice Address - Fax:877-770-7177
Is Sole Proprietor?:No
Enumeration Date:2010-01-06
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3010956363L00000X
VA0024184082363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner