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General NPI Number Information
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NPI Number | 1629569488
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Entity Type | Individual
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Provider Name | AMANDA LEE WYATT
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Gender | Female
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Dates
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Enumeration Date | 05/28/2018
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Last Update Date | 05/28/2018
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Provider Practice Location Address
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Address Line | 1340 S LAUREL RD
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City | LONDON
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State | KY
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Zip | 40744-8304
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Country | US
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Telephone | 855-591-0092
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Fax |
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Provider Business Mailing Address
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Address Line | 139 DANTLEY DR
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City | CORBIN
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State | KY
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Zip | 40701-3102
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Country | US
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Telephone | 606-224-0136
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171M00000X
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Taxonomy Name | Case Manager/Care Coordinator
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License Number |
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License Number State |
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