Provider Demographics
NPI:1922633056
Name:WYCKOFF, DANYALLE MARIE (NP)
Entity Type:Individual
Prefix:
First Name:DANYALLE
Middle Name:MARIE
Last Name:WYCKOFF
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3201 SHERMAN PARK DR
Mailing Address - Street 2:
Mailing Address - City:SAULT SAINTE MARIE
Mailing Address - State:MI
Mailing Address - Zip Code:49783-1117
Mailing Address - Country:US
Mailing Address - Phone:906-440-7040
Mailing Address - Fax:
Practice Address - Street 1:3201 SHERMAN PARK DR
Practice Address - Street 2:
Practice Address - City:SAULT SAINTE MARIE
Practice Address - State:MI
Practice Address - Zip Code:49783-1117
Practice Address - Country:US
Practice Address - Phone:906-440-7040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-09
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704304100363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner