Healthcare Provider Details

I. General information

NPI: 1417811779
Provider Name (Legal Business Name): WYATT N POWELL-GALLARDO RN, BSN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2025
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 GETTYSBURG DR
CHEYENNE WY
82001-7434
US

IV. Provider business mailing address

920 GETTYSBURG DR
CHEYENNE WY
82001-7434
US

V. Phone/Fax

Practice location:
  • Phone: 307-761-4719
  • Fax:
Mailing address:
  • Phone: 307-761-4749
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number45371
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: