Provider Demographics
NPI:1609328566
Name:WYSE, CHERYL A (STNA)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:A
Last Name:WYSE
Suffix:
Gender:F
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20-29 STATE HWY 6
Mailing Address - Street 2:
Mailing Address - City:RIDGEVILLE CORNERS
Mailing Address - State:OH
Mailing Address - Zip Code:43555-0103
Mailing Address - Country:US
Mailing Address - Phone:419-956-1224
Mailing Address - Fax:
Practice Address - Street 1:20-249 STATE HIGHWAY 6
Practice Address - Street 2:
Practice Address - City:RIDGEVILLE CORNERS
Practice Address - State:OH
Practice Address - Zip Code:43555-0103
Practice Address - Country:US
Practice Address - Phone:419-956-1224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-26
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH401390490512374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0079858Medicaid