Healthcare Provider Details

I. General information

NPI: 1194001594
Provider Name (Legal Business Name): KELLY JO WYSOCKI-EMERY RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/29/2011
Last Update Date: 10/26/2022
Certification Date: 10/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

233 FULTON ST E # 114E
GRAND RAPIDS MI
49503-3200
US

IV. Provider business mailing address

335 BRIDGE ST NW APT 1400
GRAND RAPIDS MI
49504-5393
US

V. Phone/Fax

Practice location:
  • Phone: 616-485-6757
  • Fax: 616-333-7710
Mailing address:
  • Phone: 616-485-6757
  • Fax: 616-333-7710

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number4704230542
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: