Healthcare Provider Details

I. General information

NPI: 1740057132
Provider Name (Legal Business Name): ANGELA LOUISE WYSOCKI CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2023
Last Update Date: 12/06/2023
Certification Date: 11/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LONGWOOD AVE
BOSTON MA
02115-5724
US

IV. Provider business mailing address

4794 WHISPERING PINES DR
SHELBY TOWNSHIP MI
48316-1561
US

V. Phone/Fax

Practice location:
  • Phone: 888-733-4662
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberRN2391013
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: