Provider Demographics
NPI:1578380093
Name:WYLAND, TRENT VERNON (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:TRENT
Middle Name:VERNON
Last Name:WYLAND
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:529 GARNSEY RD
Mailing Address - Street 2:
Mailing Address - City:FAIRPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14450-3924
Mailing Address - Country:US
Mailing Address - Phone:585-645-8073
Mailing Address - Fax:
Practice Address - Street 1:1183 MONROE AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14620-1662
Practice Address - Country:US
Practice Address - Phone:585-256-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-25
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY750145-01163WP0808X
NYF406369-01363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health