Healthcare Provider Details

I. General information

NPI: 1588339717
Provider Name (Legal Business Name): HEATHER DAWN WYCKOFF CNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2021
Last Update Date: 08/10/2021
Certification Date: 08/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 VALLEY DR
MANNINGTON WV
26582-3043
US

IV. Provider business mailing address

116 VALLEY DR
MANNINGTON WV
26582-3043
US

V. Phone/Fax

Practice location:
  • Phone: 304-825-6364
  • Fax:
Mailing address:
  • Phone: 304-825-6246
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: