Provider Demographics
NPI:1700228269
Name:WYCOFF, KENNETH N (CNP)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:N
Last Name:WYCOFF
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10701 EAST BLVD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44106-1702
Mailing Address - Country:US
Mailing Address - Phone:330-489-4600
Mailing Address - Fax:216-229-2642
Practice Address - Street 1:733 MARKET AVE S
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44702-2165
Practice Address - Country:US
Practice Address - Phone:330-489-4600
Practice Address - Fax:216-229-2642
Is Sole Proprietor?:No
Enumeration Date:2013-07-25
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.14738363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0088611Medicaid
OH0088611Medicaid