Provider Demographics
NPI:1912342734
Name:WYSOCKI, NICOLE ANNE (MD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ANNE
Last Name:WYSOCKI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6410 FANNIN ST
Mailing Address - Street 2:SUITE 1014
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-3000
Mailing Address - Country:US
Mailing Address - Phone:832-325-7080
Mailing Address - Fax:713-512-2239
Practice Address - Street 1:1700 MEDICAL CENTER PKWY
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37129-2245
Practice Address - Country:US
Practice Address - Phone:615-396-4694
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-07
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN615192084N0400X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program