Healthcare Provider Details

I. General information

NPI: 1174273478
Provider Name (Legal Business Name): KATHLEEN WYKOFF
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2022
Last Update Date: 12/15/2023
Certification Date: 12/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N STATE OF FRANKLIN RD
JOHNSON CITY TN
37604-6035
US

IV. Provider business mailing address

400 N STATE OF FRANKLIN RD
JOHNSON CITY TN
37604-6035
US

V. Phone/Fax

Practice location:
  • Phone: 423-431-6111
  • Fax:
Mailing address:
  • Phone: 423-431-6111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number235803
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number35209
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: