Provider Demographics
NPI:1427890011
Name:WYMORE, KELSEY JANE
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:JANE
Last Name:WYMORE
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 1:1204 24TH ST NW APT 2
Mailing Address - Street 2:
Mailing Address - City:MANDAN
Mailing Address - State:ND
Mailing Address - Zip Code:58554-1585
Mailing Address - Country:US
Mailing Address - Phone:701-391-7565
Mailing Address - Fax:
Practice Address - Street 1:100 W MAIN AVE APT 205
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-4187
Practice Address - Country:US
Practice Address - Phone:701-264-0694
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-12
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant