Healthcare Provider Details

I. General information

NPI: 1831542620
Provider Name (Legal Business Name): KATHERINE WYATT NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2016
Last Update Date: 07/02/2021
Certification Date: 07/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3772 TIBBETTS ST
RIVERSIDE CA
92506-2605
US

IV. Provider business mailing address

3772 TIBBETTS ST
RIVERSIDE CA
92506-2605
US

V. Phone/Fax

Practice location:
  • Phone: 951-222-1523
  • Fax:
Mailing address:
  • Phone: 951-222-1523
  • Fax: 951-682-7904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number790215
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95004936
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: