Healthcare Provider Details

I. General information

NPI: 1427569425
Provider Name (Legal Business Name): VANESSA PAULINE WYATT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2017
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 ARNOLD ST
WAKEFIELD RI
02879-3701
US

IV. Provider business mailing address

268 KINGSTOWN RD
NARRAGANSETT RI
02882-3237
US

V. Phone/Fax

Practice location:
  • Phone: 401-789-9390
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDP01055
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: