Healthcare Provider Details

I. General information

NPI: 1760812234
Provider Name (Legal Business Name): KELLY AMANDA WYCOFF HIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2013
Last Update Date: 01/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

359 S LANDMARK AVE
BLOOMINGTON IN
47403-5002
US

IV. Provider business mailing address

215 SHUMAN BLVD STE 401
NAPERVILLE IL
60563-8123
US

V. Phone/Fax

Practice location:
  • Phone: 812-334-3919
  • Fax: 812-334-3936
Mailing address:
  • Phone: 630-303-5380
  • Fax: 630-303-5385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number17001391A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: