Healthcare Provider Details

I. General information

NPI: 1407656366
Provider Name (Legal Business Name): KAREN WYCKOFF
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2025
Last Update Date: 03/18/2025
Certification Date: 03/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

86 RIVER ST
HORNELL NY
14843-2265
US

IV. Provider business mailing address

788 COUNTY ROAD 5
BOLIVAR NY
14715-9610
US

V. Phone/Fax

Practice location:
  • Phone: 607-282-5201
  • Fax: 585-335-5061
Mailing address:
  • Phone: 607-377-6035
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number457418-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: