Provider Demographics
NPI:1962131417
Name:WYNN, KRISTEN DECKER
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:DECKER
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 1:306 HOLLY CREEK DR
Mailing Address - Street 2:
Mailing Address - City:IRMO
Mailing Address - State:SC
Mailing Address - Zip Code:29063-8970
Mailing Address - Country:US
Mailing Address - Phone:678-634-8896
Mailing Address - Fax:
Practice Address - Street 1:7 INDEPENDENCE PT STE 300
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-4569
Practice Address - Country:US
Practice Address - Phone:864-454-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-09
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN277737163W00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse