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General NPI Number Information
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NPI Number | 1649358847
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Entity Type | Individual
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Provider Name | LACEY SHAYANN WYATT A.P.N.
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Gender | Female
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Dates
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Enumeration Date | 11/02/2006
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Last Update Date | 06/15/2018
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Provider Practice Location Address
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Address Line | 1707 LINWOOD DR STE A
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City | PARAGOULD
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State | AR
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Zip | 72450
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Country | US
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Telephone | 870-236-2202
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Fax |
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Provider Business Mailing Address
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Address Line | 1707 LINWOOD DR STE A
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City | PARAGOULD
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State | AR
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Zip | 72450-5365
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Country | US
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Telephone | 870-236-2202
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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 | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | APN0000014041
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License Number State | TN
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Taxonomy #2
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | A01865
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License Number State | AR
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