Healthcare Provider Details

I. General information

NPI: 1164129045
Provider Name (Legal Business Name): KAITLYN WYATT NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2023
Last Update Date: 03/06/2024
Certification Date: 03/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10090 E LIPPINCOTT BLVD
DAVISON MI
48423-9151
US

IV. Provider business mailing address

10090 E LIPPINCOTT BLVD
DAVISON MI
48423-9151
US

V. Phone/Fax

Practice location:
  • Phone: 810-653-1130
  • Fax:
Mailing address:
  • Phone: 810-653-1130
  • Fax: 810-653-8589

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704292460
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: