Healthcare Provider Details

I. General information

NPI: 1801158746
Provider Name (Legal Business Name): GINA WYATT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2012
Last Update Date: 06/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2778 COUNTRY CLUB DR
HAMPSTEAD NC
28443-8028
US

IV. Provider business mailing address

2778 COUNTRY CLUB DR
HAMPSTEAD NC
28443-8028
US

V. Phone/Fax

Practice location:
  • Phone: 910-270-5223
  • Fax:
Mailing address:
  • Phone: 910-270-5223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number6550
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: