Provider Demographics
NPI:1073000816
Name:WYNES, CARMEN MARIE (NP)
Entity type:Individual
Prefix:MS
First Name:CARMEN
Middle Name:MARIE
Last Name:WYNES
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 RIVER WALK PKWY STE 101
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-6893
Mailing Address - Country:US
Mailing Address - Phone:757-983-1777
Mailing Address - Fax:252-275-7507
Practice Address - Street 1:213 RIVER WALK PKWY STE 101
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-6893
Practice Address - Country:US
Practice Address - Phone:757-983-1777
Practice Address - Fax:757-507-9043
Is Sole Proprietor?:No
Enumeration Date:2018-04-17
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCWYNE-WLK81363LP2300X
VA0024175910363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1750021325Medicaid