Provider Demographics
NPI:1750300877
Name:WYNNE, ALISON E (ARNP)
Entity type:Individual
Prefix:
First Name:ALISON
Middle Name:E
Last Name:WYNNE
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:INTERMOUNTAIN HEALTHCARE
Mailing Address - Street 2:5121 S COTTONWOOD ST
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107
Mailing Address - Country:US
Mailing Address - Phone:801-507-4000
Mailing Address - Fax:801-507-4811
Practice Address - Street 1:INTERMOUNTAIN HEALTHCARE
Practice Address - Street 2:5121 S COTTONWOOD ST
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107
Practice Address - Country:US
Practice Address - Phone:801-507-4000
Practice Address - Fax:801-507-4811
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2018-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00158616163W00000X
WAAP30006970363LA2100X
SC4330363LA2100X
UT10952123-4405363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA20554UOtherREGENCE BLUESHIELD
WA9645250Medicaid
WA0197481OtherLABOR & INDUSTRY
WA8855482Medicare PIN
WA9645250Medicaid