Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LA2200X | Nurse Practitioner - Adult Health | 251261 | TX |
N | 363LG0600X | Nurse Practitioner - Gerontology | 251261 | TX |
NPI | 1023069242 |
---|---|
Provider Name | Katrenia J Wycough |
First Address | Minnetonka, MN 55343-9664 |
Second Address | Minnetonka, MN 55343-9664 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/05/2006 |
Last Update Date | 17/09/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
29335903 | (05) | TX |
P03368 | (02) | TX |