Healthcare Provider Details

I. General information

NPI: 1124308754
Provider Name (Legal Business Name): MICHELLE GILLUM WYATT R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2011
Last Update Date: 08/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 LAKE OTIS PKWY
ANCHORAGE AK
99508-5229
US

IV. Provider business mailing address

12000 TIMBERLANE DR
ANCHORAGE AK
99515-3324
US

V. Phone/Fax

Practice location:
  • Phone: 907-550-6100
  • Fax:
Mailing address:
  • Phone: 907-727-6070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number23503
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License Number23503
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: