Provider Demographics
NPI:1265449797
Name:WYMAN, MARY (FNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:WYMAN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:523 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-3406
Mailing Address - Country:US
Mailing Address - Phone:707-869-2849
Mailing Address - Fax:707-869-1477
Practice Address - Street 1:16319 THIRD STREET
Practice Address - Street 2:
Practice Address - City:GUERNEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95446
Practice Address - Country:US
Practice Address - Phone:707-869-2849
Practice Address - Fax:707-869-1477
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP13614363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ73222ZOtherMEDICARE PART B
CANP13614OtherSTATE LICENSE NUMBER
CAQ14735Medicare UPIN
ZZZ73222ZOtherMEDICARE PART B