Provider Demographics
NPI:1659011633
Name:WYNN, NICKEYA (MD)
Entity type:Individual
Prefix:
First Name:NICKEYA
Middle Name:
Last Name:WYNN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3912 POINTE N
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30506-5385
Mailing Address - Country:US
Mailing Address - Phone:678-512-9633
Mailing Address - Fax:
Practice Address - Street 1:2748 WINDER HWY
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:GA
Practice Address - Zip Code:30549-5466
Practice Address - Country:US
Practice Address - Phone:706-367-4455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-29
Last Update Date:2025-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA105526207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine