Provider Demographics
NPI:1750546537
Name:WYNN, JENNIFER (ARNP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:WYNN
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:PLANSKY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:200 NE MOTHER JOSEPH PL STE 210
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98664-3295
Mailing Address - Country:US
Mailing Address - Phone:360-254-6161
Mailing Address - Fax:360-449-1146
Practice Address - Street 1:200 NE MOTHER JOSEPH PL STE 300
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664
Practice Address - Country:US
Practice Address - Phone:360-254-6161
Practice Address - Fax:360-449-1146
Is Sole Proprietor?:No
Enumeration Date:2008-07-22
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00157320163W00000X
OR200240758RN163W00000X
OR200950128NP363LF0000X
WAAP60107358363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0255099OtherLABOR & INDUSTRIES
WA9662735Medicaid
WAG8885395Medicare PIN