MEDICARE: WYATT N POWELL-GALLARDO RN, BSN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WC0400X	Case Management Registered Nurse	45371	WY

General Provider Information

NPI Number	:	1417811779
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WYATT N POWELL-GALLARDO RN, BSN

Provider Business Mailing Address
First Line	:	920 GETTYSBURG DR
Second Line	:
City	:	CHEYENNE
State	:	WY
Zip	:	82001-7434
Country	:	US
Telephone Number	:	307-761-4749
Fax Number	:

Provider Business Practice Location Address
First Line	:	920 GETTYSBURG DR
Second Line	:
City	:	CHEYENNE
State	:	WY
Zip	:	82001-7434
Country	:	US
Telephone Number	:	307-761-4719
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/11/2025
Last Update Date	:	12/11/2025

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