Healthcare Provider Details

I. General information

NPI: 1538423579
Provider Name (Legal Business Name): MS. VANESSA WYCKOFF
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2012
Last Update Date: 06/27/2024
Certification Date: 06/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 CYPRESS DR
WOODBURY NY
11797-1502
US

IV. Provider business mailing address

42 VILLAS CIR
MELVILLE NY
11747-3055
US

V. Phone/Fax

Practice location:
  • Phone: 516-672-0468
  • Fax:
Mailing address:
  • Phone: 516-672-0468
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number635931121
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: