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General NPI Number Information
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NPI Number | 1902772148
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Entity Type | Individual
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Provider Name | EBONY WYATT CPT
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Gender | Female
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Dates
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Enumeration Date | 10/15/2025
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Last Update Date | 10/15/2025
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Provider Practice Location Address
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Address Line | 811 MAIN ST STE 17
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City | COLUMBIA
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State | MS
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Zip | 39429-2711
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Country | US
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Telephone | 601-549-3006
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Fax |
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Provider Business Mailing Address
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Address Line | 102 LEXINGTON DR
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City | HATTIESBURG
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State | MS
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Zip | 39402-9313
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Country | US
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Telephone | 601-549-3006
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Fax | 601-549-3006
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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 | 374700000X
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Taxonomy Name | Technician
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License Number | Z6Y4T5D7
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License Number State | MS
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