Provider Demographics
NPI:1053377549
Name:WYNN, CHARLOTTE CASEY (CRNP)
Entity type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:CASEY
Last Name:WYNN
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1735 KESTWICK CIR
Mailing Address - Street 2:
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35226-2347
Mailing Address - Country:US
Mailing Address - Phone:334-782-2642
Mailing Address - Fax:
Practice Address - Street 1:9900 BREN RD E
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55343-9664
Practice Address - Country:US
Practice Address - Phone:334-272-9684
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-24
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-040730363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051029766OtherBLUE CROSS
AL000029766Medicaid
AL000029766Medicaid
AL051029766OtherBLUE CROSS