Healthcare Provider Details

I. General information

NPI: 1871402909
Provider Name (Legal Business Name): WYATT SPENCER
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2026
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 212
GYPSY WV
26361-0212
US

IV. Provider business mailing address

PO BOX 212
GYPSY WV
26361-0212
US

V. Phone/Fax

Practice location:
  • Phone: 304-627-4497
  • Fax:
Mailing address:
  • Phone: 304-627-4497
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: