Healthcare Provider Details

I. General information

NPI: 1952457467
Provider Name (Legal Business Name): MARY WYCKOFF PHD, ACNP, BC, NNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY WYCKOFF PHD, FNP, BC, CCNS

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 10/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2315 STOCKTON AVE
SACRAMENTO CA
95817
US

IV. Provider business mailing address

5373 MONALEE AVE
SACRAMENTO CA
95819
US

V. Phone/Fax

Practice location:
  • Phone: 916-703-3395
  • Fax:
Mailing address:
  • Phone: 305-904-3661
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number1703712
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number21525
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number21525
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
License Number21525
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code364SA2100X
TaxonomyAcute Care Clinical Nurse Specialist
License Number3812
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: