Healthcare Provider Details

I. General information

NPI: 1225534027
Provider Name (Legal Business Name): KYLEY JO WYSS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KYLEY JO MAXHEIMER

II. Dates (important events)

Enumeration Date: 04/02/2018
Last Update Date: 06/30/2023
Certification Date: 06/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7777 HENNESSY BLVD STE 211
BATON ROUGE LA
70808-4365
US

IV. Provider business mailing address

1163 W PEACHTREE ST NE APT 3007
ATLANTA GA
30309-4550
US

V. Phone/Fax

Practice location:
  • Phone: 225-765-7163
  • Fax:
Mailing address:
  • Phone: 217-280-0573
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number327880
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number95628
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: