Basic Information
| Provider Information | |||||||||
| NPI: | 1033529524 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WYNN | ||||||||
| FirstName: | TERRIE | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LPN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FOSTER | ||||||||
| OtherFirstName: | TERRIE | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2202 E 48TH ST. | ||||||||
| Address2: | |||||||||
| City: | DAVENPORT | ||||||||
| State: | IA | ||||||||
| PostalCode: | 528071214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5633431810 | ||||||||
| FaxNumber: | 5633261901 | ||||||||
| Practice Location | |||||||||
| Address1: | 2202 E 48TH ST. | ||||||||
| Address2: | |||||||||
| City: | DAVENPORT | ||||||||
| State: | IA | ||||||||
| PostalCode: | 528071214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5633431810 | ||||||||
| FaxNumber: | 5633261901 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2014 | ||||||||
| LastUpdateDate: | 09/28/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | 220930 | NY | Y | Nursing Service Providers | Licensed Practical Nurse |
No ID Information.