Provider Demographics
NPI:1871870980
Name:WYNN, KATHLEEN (RN)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:WYNN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:
Other - Last Name:BADTEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:400 WEST APACHE DR
Mailing Address - Street 2:PO BOX 860
Mailing Address - City:WHITERIVER
Mailing Address - State:AZ
Mailing Address - Zip Code:85941
Mailing Address - Country:US
Mailing Address - Phone:928-338-4911
Mailing Address - Fax:928-338-3681
Practice Address - Street 1:400 APACHE DRIVE
Practice Address - Street 2:
Practice Address - City:WHITERIVER
Practice Address - State:AZ
Practice Address - Zip Code:85941
Practice Address - Country:US
Practice Address - Phone:928-338-4911
Practice Address - Fax:928-338-3681
Is Sole Proprietor?:No
Enumeration Date:2011-11-03
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN151971163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health