Healthcare Provider Details

I. General information

NPI: 1780397067
Provider Name (Legal Business Name): KATELYN WYETH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2023
Last Update Date: 01/02/2023
Certification Date: 01/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 E 17TH ST
BLOOMINGTON IN
47408-1578
US

IV. Provider business mailing address

400 E MELROSE AVE
BLOOMINGTON IN
47401-1904
US

V. Phone/Fax

Practice location:
  • Phone: 812-855-1966
  • Fax:
Mailing address:
  • Phone: 630-414-2408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: