Healthcare Provider Details

I. General information

NPI: 1740592617
Provider Name (Legal Business Name): KATIE LYNN WYSOCKI PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2010
Last Update Date: 02/20/2024
Certification Date: 02/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 HOSPITAL DR STE 108
BENNINGTON VT
05201-5010
US

IV. Provider business mailing address

140 HOSPITAL DR
BENNINGTON VT
05201-5009
US

V. Phone/Fax

Practice location:
  • Phone: 802-447-5519
  • Fax:
Mailing address:
  • Phone: 802-447-5519
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA100218
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0550031179
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: