Healthcare Provider Details

I. General information

NPI: 1003055757
Provider Name (Legal Business Name): ANDREA LYNNE WYDMAN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ANDI WYDMAN RN

II. Dates (important events)

Enumeration Date: 02/19/2009
Last Update Date: 02/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

959 BROAD BLVD
DAYTON OH
45419-2029
US

IV. Provider business mailing address

959 BROAD BLVD
DAYTON OH
45419-2029
US

V. Phone/Fax

Practice location:
  • Phone: 937-694-2931
  • Fax: 937-298-6388
Mailing address:
  • Phone: 937-694-2931
  • Fax: 937-298-6388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License NumberRN130797
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License NumberRN130797
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License NumberRN 130797
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: