Healthcare Provider Details

I. General information

NPI: 1720128069
Provider Name (Legal Business Name): KENNETH JAMES WYSOCKI PHD, FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 07/08/2020
Certification Date: 07/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9900 BREN RD E
MINNETONKA MN
55343-9664
US

IV. Provider business mailing address

5444 E LEWIS AVE
PHOENIX AZ
85008-2616
US

V. Phone/Fax

Practice location:
  • Phone: 602-702-3825
  • Fax:
Mailing address:
  • Phone: 602-702-3825
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN068583
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: