Provider Demographics
NPI:1992960785
Name:WYNNE, JESSICA T (ARNP)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:T
Last Name:WYNNE
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:CLAIRE
Other - Last Name:TRAGESSER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1616 CORNWALL AVE STE 205
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-4642
Mailing Address - Country:US
Mailing Address - Phone:360-676-6177
Mailing Address - Fax:360-527-8778
Practice Address - Street 1:6060 PORTAL WAY
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:WA
Practice Address - Zip Code:98248-7833
Practice Address - Country:US
Practice Address - Phone:360-676-6177
Practice Address - Fax:360-671-3574
Is Sole Proprietor?:No
Enumeration Date:2008-07-22
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00163760163W00000X
WAAP60054777363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9658832Medicaid
WAG8876610OtherMEDICARE PTAN