Healthcare Provider Details

I. General information

NPI: 1912548165
Provider Name (Legal Business Name): THERESA WYSOCHANSKI RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2019
Last Update Date: 09/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 LINCOLN AVE
LOCKPORT NY
14094-5531
US

IV. Provider business mailing address

130 BEATTIE AVE
LOCKPORT NY
14094-5023
US

V. Phone/Fax

Practice location:
  • Phone: 716-471-7334
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number754909
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: