Healthcare Provider Details

I. General information

NPI: 1619043395
Provider Name (Legal Business Name): CAROL ANN WYATT RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CAROL ANN BYRAM RN

II. Dates (important events)

Enumeration Date: 11/27/2006
Last Update Date: 01/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 SE 3RD AVE
ESTACADA OR
97023-8563
US

IV. Provider business mailing address

PO BOX 514
ESTACADA OR
97023-0514
US

V. Phone/Fax

Practice location:
  • Phone: 503-630-6787
  • Fax: 503-630-6787
Mailing address:
  • Phone: 503-630-6787
  • Fax: 503-630-6787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number000032351RN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: