Provider Demographics
NPI:1316254709
Name:WYNN, ANITA L (CRNA)
Entity type:Individual
Prefix:
First Name:ANITA
Middle Name:L
Last Name:WYNN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:LYN
Other - Middle Name:
Other - Last Name:WYNN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:620 SKYLINE DRIVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301
Mailing Address - Country:US
Mailing Address - Phone:731-541-7070
Mailing Address - Fax:731-541-7075
Practice Address - Street 1:620 SKYLINE DRIVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301
Practice Address - Country:US
Practice Address - Phone:731-541-7070
Practice Address - Fax:731-541-7075
Is Sole Proprietor?:No
Enumeration Date:2010-09-07
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN15193367500000X
TNRN163107163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse