Provider Demographics
NPI:1992263826
Name:WYANT, LEEANN (LPN)
Entity type:Individual
Prefix:
First Name:LEEANN
Middle Name:
Last Name:WYANT
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 FELLER RD
Mailing Address - Street 2:
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12603-2918
Mailing Address - Country:US
Mailing Address - Phone:845-901-1295
Mailing Address - Fax:
Practice Address - Street 1:230 NORTH RD
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12601-1328
Practice Address - Country:US
Practice Address - Phone:845-486-8880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-11
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY315378164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY315378Medicaid