Healthcare Provider Details

I. General information

NPI: 1740882638
Provider Name (Legal Business Name): TARA WYSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2020
Last Update Date: 11/15/2020
Certification Date: 11/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24124 STATE ROUTE 2
ARCHBOLD OH
43502-9453
US

IV. Provider business mailing address

24124 STATE ROUTE 2
ARCHBOLD OH
43502-9453
US

V. Phone/Fax

Practice location:
  • Phone: 419-572-1944
  • Fax:
Mailing address:
  • Phone: 419-572-1944
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: