Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LW0102X | Nurse Practitioner - Women's Health | SP021240 | PA |
NPI | 1053930958 |
---|---|
Provider Name | Renee Wynn |
First Address | Philadelphia, PA 19142-1209 |
Second Address | Philadelphia, PA 19141-3030 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 10/04/2020 |
Last Update Date | 10/04/2020 |