Provider Demographics
NPI:1114708211
Name:WYAN, ELIZABETH
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:WYAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:963 MARION AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45229-1924
Mailing Address - Country:US
Mailing Address - Phone:513-616-7531
Mailing Address - Fax:
Practice Address - Street 1:2216 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:FORT MITCHELL
Practice Address - State:KY
Practice Address - Zip Code:41017-2965
Practice Address - Country:US
Practice Address - Phone:859-412-7484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-13
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH07091970173C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173C00000XOther Service ProvidersReflexologistGroup - Single Specialty