Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LN0005X | Nurse Practitioner - Neonatal (Critical Care) | RN079004 | GA |
NPI | 1083012561 |
---|---|
Provider Name | Beverly Wynne |
First Address | Kennesaw, GA 30152-7722 |
Second Address | Marietta, GA 30060-1101 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/12/2014 |
Last Update Date | 15/12/2014 |