Healthcare Provider Details

I. General information

NPI: 1114185907
Provider Name (Legal Business Name): SHELLEY LYNN WYSE P.A.-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SHELLEY LYNN WELLS

II. Dates (important events)

Enumeration Date: 05/28/2008
Last Update Date: 04/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

388 DAMASCUS RD
MARYSVILLE OH
43040-5535
US

IV. Provider business mailing address

200 BRADENTON AVE
DUBLIN OH
43017-7515
US

V. Phone/Fax

Practice location:
  • Phone: 937-578-4040
  • Fax: 937-578-2591
Mailing address:
  • Phone: 937-578-4040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number50-00-1164
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: