Healthcare Provider Details

I. General information

NPI: 1629569488
Provider Name (Legal Business Name): AMANDA LEE WYATT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2018
Last Update Date: 05/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 S LAUREL RD
LONDON KY
40744-8304
US

IV. Provider business mailing address

139 DANTLEY DR
CORBIN KY
40701-3102
US

V. Phone/Fax

Practice location:
  • Phone: 855-591-0092
  • Fax:
Mailing address:
  • Phone: 606-224-0136
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: