Healthcare Provider Details

I. General information

NPI: 1023069242
Provider Name (Legal Business Name): KATRENIA J WYCOUGH RN, A/GNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 09/17/2020
Certification Date: 09/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9900 BREN ROAD EAST
MINNETONKA MN
55343-9664
US

IV. Provider business mailing address

9900 BREN RD E
MINNETONKA MN
55343-9664
US

V. Phone/Fax

Practice location:
  • Phone: 903-681-8334
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number251261
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number251261
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: