Provider Demographics
NPI:1952457467
Name:WYCKOFF, MARY (PHD, ACNP, BC, NNP)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:
Last Name:WYCKOFF
Suffix:
Gender:F
Credentials:PHD, ACNP, BC, NNP
Other - Prefix:DR
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:WYCKOFF
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD, FNP, BC, CCNS
Mailing Address - Street 1:5373 MONALEE AVE
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95819
Mailing Address - Country:US
Mailing Address - Phone:305-904-3661
Mailing Address - Fax:
Practice Address - Street 1:2315 STOCKTON AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817
Practice Address - Country:US
Practice Address - Phone:916-703-3395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1703712363LA2100X
CA21525363LA2100X, 363LF0000X, 363LN0005X
CA3812364SA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care
No364SA2100XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAcute Care