Healthcare Provider Details

I. General information

NPI: 1730011057
Provider Name (Legal Business Name): ERICA LEE WYATT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2026
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

717 LINCOLN BLVD
VENICE CA
90291-2845
US

IV. Provider business mailing address

2701 W VERNON AVE
LOS ANGELES CA
90008-3931
US

V. Phone/Fax

Practice location:
  • Phone: 310-399-9883
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number246495
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: