Healthcare Provider Details

I. General information

NPI: 1861222143
Provider Name (Legal Business Name): STACY WYATT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/02/2024
Last Update Date: 08/02/2024
Certification Date: 08/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 WOODWAY DR STE 306W
HOUSTON TX
77056-1828
US

IV. Provider business mailing address

4801 WOODWAY DR STE 306W
HOUSTON TX
77056-1828
US

V. Phone/Fax

Practice location:
  • Phone: 832-225-3345
  • Fax: 713-583-1504
Mailing address:
  • Phone: 832-225-3345
  • Fax: 713-583-1504

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number1158846
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: