Healthcare Provider Details

I. General information

NPI: 1073426532
Provider Name (Legal Business Name): WYATT GRAUPE LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2026
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1916 24TH AVE
GULFPORT MS
39501-2975
US

IV. Provider business mailing address

15329 JOHN SMITH RD
VANCLEAVE MS
39565-7969
US

V. Phone/Fax

Practice location:
  • Phone: 228-313-9208
  • Fax:
Mailing address:
  • Phone: 228-424-3249
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: