Provider Demographics
NPI:1124730296
Name:WYZYKOWSKI, ELLEN
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:WYZYKOWSKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:166 SHERWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:DANIELSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30633-5891
Mailing Address - Country:US
Mailing Address - Phone:706-254-7042
Mailing Address - Fax:
Practice Address - Street 1:455 EPPS BRIDGE PKWY STE 202
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-3347
Practice Address - Country:US
Practice Address - Phone:706-775-8907
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-20
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN072856163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice