Provider Demographics
NPI:1194001594
Name:WYSOCKI-EMERY, KELLY JO (RN)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:JO
Last Name:WYSOCKI-EMERY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:335 BRIDGE ST NW APT 1400
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-5393
Mailing Address - Country:US
Mailing Address - Phone:616-485-6757
Mailing Address - Fax:616-333-7710
Practice Address - Street 1:233 FULTON ST E # 114E
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-3200
Practice Address - Country:US
Practice Address - Phone:616-485-6757
Practice Address - Fax:616-333-7710
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-29
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704230542163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant