Provider Demographics
NPI:1780669259
Name:WYCINSKI, KELLY LYNN (CNP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNN
Last Name:WYCINSKI
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:859 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MALTA
Mailing Address - State:OH
Mailing Address - Zip Code:43758-9007
Mailing Address - Country:US
Mailing Address - Phone:740-962-6111
Mailing Address - Fax:740-962-2182
Practice Address - Street 1:2725 PINKERTON LN
Practice Address - Street 2:
Practice Address - City:ZANESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43701-1513
Practice Address - Country:US
Practice Address - Phone:740-891-9000
Practice Address - Fax:740-891-9001
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.06287363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2366514Medicaid
WYNP11543Medicare PIN