Provider Demographics
NPI:1609131978
Name:WYNN, JACQUELINE (ARNP)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:WYNN
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:HURLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:2675 WINKLER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:239-599-2625
Practice Address - Street 1:800 GOODLETTE RD N STE 340
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34102-5412
Practice Address - Country:US
Practice Address - Phone:239-206-1624
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-11
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9282668363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY0HN1OtherFL BC
FLY0HN1OtherFL BC