Provider Demographics
NPI:1003055757
Name:WYDMAN, ANDREA LYNNE (RN)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:LYNNE
Last Name:WYDMAN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MS
Other - First Name:ANDI
Other - Middle Name:
Other - Last Name:WYDMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:959 BROAD BLVD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45419-2029
Mailing Address - Country:US
Mailing Address - Phone:937-694-2931
Mailing Address - Fax:937-298-6388
Practice Address - Street 1:959 BROAD BLVD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45419-2029
Practice Address - Country:US
Practice Address - Phone:937-694-2931
Practice Address - Fax:937-298-6388
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-19
Last Update Date:2009-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN130797163WC0400X, 163WH0200X
OHRN 130797163WW0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163WW0000XNursing Service ProvidersRegistered NurseWound Care