Healthcare Provider Details

I. General information

NPI: 1033477526
Provider Name (Legal Business Name): CHERI LYNNE WYATT RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2012
Last Update Date: 05/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1114 S BUTLER LN
INDEPENDENCE MO
64056-3056
US

IV. Provider business mailing address

1114 S BUTLER LN
INDEPENDENCE MO
64056-3056
US

V. Phone/Fax

Practice location:
  • Phone: 816-665-5398
  • Fax:
Mailing address:
  • Phone: 816-665-5398
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number2005031816
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: