Provider Demographics
NPI:1649661992
Name:WYCKOFF, NIGEL
Entity type:Individual
Prefix:
First Name:NIGEL
Middle Name:
Last Name:WYCKOFF
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2638 FRANCIS ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49203-4617
Mailing Address - Country:US
Mailing Address - Phone:517-581-8084
Mailing Address - Fax:
Practice Address - Street 1:2638 FRANCIS ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49203-4617
Practice Address - Country:US
Practice Address - Phone:517-581-8084
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-09
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703110249164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse