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NPI Code Detail

MEDICARE: MYKALA RAE WISWELL

MEDICARE: MYKALA RAE WISWELL
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1225100000XPhysical Therapist040.0134189VT

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1952912347
Entity Type Code : Individual
Provider Name (Legal Business Name) : MYKALA RAE WISWELL
Provider Business Mailing Address
First Line : PO BOX 905
Second Line :
City : ST JOHNSBURY
State : VT
Zip : 05819-0905
Country : US
Telephone Number : 802-748-8141
Fax Number : 802-748-4098
Provider Business Practice Location Address
First Line : 569 MAIN ST
Second Line :
City : LYNDONVILLE
State : VT
Zip : 05851-9240
Country : US
Telephone Number : 802-626-4224
Fax Number : 802-748-5024
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/11/2020
Last Update Date : 11/06/2024

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Directions to “ MYKALA RAE WISWELL ” Practice Location

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