Provider Demographics
NPI:1003570516
Name:WYRICK, KENNETH DWAYNE
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:DWAYNE
Last Name:WYRICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1445 N STATE ROUTE 201
Mailing Address - Street 2:
Mailing Address - City:CASSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45312-9548
Mailing Address - Country:US
Mailing Address - Phone:937-418-4526
Mailing Address - Fax:
Practice Address - Street 1:1445 N STATE ROUTE 201
Practice Address - Street 2:
Practice Address - City:CASSTOWN
Practice Address - State:OH
Practice Address - Zip Code:45312-9548
Practice Address - Country:US
Practice Address - Phone:193-741-8452
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-30
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide