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General NPI Number Information
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NPI Number | 1114409422
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Entity Type | Organization
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Legal Business Name | JULIE WYATT DERMATOLOGY CLINIC, PLLC
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Dates
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Enumeration Date | 09/04/2018
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Last Update Date | 09/04/2018
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Provider Practice Location Address
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Address Line | 3000 OLD CANTON RD STE 430
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City | JACKSON
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State | MS
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Zip | 39216-4225
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Country | US
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Telephone | 601-982-5441
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Fax | 601-982-5442
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Provider Business Mailing Address
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Address Line | 3000 OLD CANTON RD STE 430
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City | JACKSON
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State | MS
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Zip | 39216-4225
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Country | US
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Telephone | 601-982-5441
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Fax | 601-982-5442
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Authorized Official
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Title or Position | OWNER
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Name | JULIE P WYATT
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Credential | MD
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Telephone | 601-982-5441
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | 20645
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License Number State | MS
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