=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568431203
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VICKI A WYSONG NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/15/2006
-----------------------------------------------------
Last Update Date | 01/14/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2333 E COUNTY ROAD 375 S
-----------------------------------------------------
City | CONNERSVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47331-9434
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-825-6234
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2333 E. COUNTY RD. 375 S.
-----------------------------------------------------
City | CONNERSVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47331-1157
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-825-6234
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 71000824A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------