Healthcare Provider Details

I. General information

NPI: 1720978877
Provider Name (Legal Business Name): MRS. RYAN CARROWAY WYATT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2025
Last Update Date: 07/08/2025
Certification Date: 07/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 GREENWOOD RD # CCU
SHREVEPORT LA
71103-3908
US

IV. Provider business mailing address

2622 BROWN ST
BOSSIER CITY LA
71111-5108
US

V. Phone/Fax

Practice location:
  • Phone: 318-212-4000
  • Fax:
Mailing address:
  • Phone: 318-658-8981
  • 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: