Provider Demographics
NPI:1588271217
Name:WYSONG, KENNETH L
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:L
Last Name:WYSONG
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 1:105 MCVEY PL
Mailing Address - Street 2:
Mailing Address - City:SPRINGBORO
Mailing Address - State:OH
Mailing Address - Zip Code:45066-1125
Mailing Address - Country:US
Mailing Address - Phone:937-231-0286
Mailing Address - Fax:
Practice Address - Street 1:105 MCVEY PL
Practice Address - Street 2:
Practice Address - City:SPRINGBORO
Practice Address - State:OH
Practice Address - Zip Code:45066-1125
Practice Address - Country:US
Practice Address - Phone:937-231-0286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-27
Last Update Date:2020-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH8305130Medicaid