Provider Demographics
NPI:1316519267
Name:WYNN, CHRISTINA MARY
Entity type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:MARY
Last Name:WYNN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2537 SUGAR CREEK CT
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-4203
Mailing Address - Country:US
Mailing Address - Phone:843-566-5659
Mailing Address - Fax:
Practice Address - Street 1:2537 SUGAR CREEK CT
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579-4203
Practice Address - Country:US
Practice Address - Phone:843-566-5659
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-12
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC224044163WA2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministratorGroup - Single Specialty