Healthcare Provider Details

I. General information

NPI: 1568431203
Provider Name (Legal Business Name): VICKI A WYSONG NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2006
Last Update Date: 01/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2333 E COUNTY ROAD 375 S
CONNERSVILLE IN
47331-9434
US

IV. Provider business mailing address

2333 E. COUNTY RD. 375 S.
CONNERSVILLE IN
47331-1157
US

V. Phone/Fax

Practice location:
  • Phone: 765-825-6234
  • Fax:
Mailing address:
  • Phone: 765-825-6234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71000824A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: