Healthcare Provider Details

I. General information

NPI: 1871577684
Provider Name (Legal Business Name): AMBER NICOLE WYATT FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2005
Last Update Date: 08/11/2022
Certification Date: 08/11/2022
Deactivation Date: 07/17/2007
Reactivation Date: 01/30/2008

III. Provider practice location address

644 HIGHWAY 114 S
SCOTTS HILL TN
38374-5023
US

IV. Provider business mailing address

PO BOX 187
SCOTTS HILL TN
38374-0187
US

V. Phone/Fax

Practice location:
  • Phone: 731-968-3646
  • Fax: 731-968-1870
Mailing address:
  • Phone: 731-614-1034
  • Fax: 731-549-1011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAPN0000008360
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: