Provider Demographics
NPI:1073752689
Name:WYATT, MARANDA NICOLE (DC)
Entity Type:Individual
Prefix:DR
First Name:MARANDA
Middle Name:NICOLE
Last Name:WYATT
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1821 COUNTY ROAD 2100 N
Mailing Address - Street 2:
Mailing Address - City:WASHBURN
Mailing Address - State:IL
Mailing Address - Zip Code:61570-9324
Mailing Address - Country:US
Mailing Address - Phone:309-303-0716
Mailing Address - Fax:
Practice Address - Street 1:2202 EASTLAND DR
Practice Address - Street 2:SUITE B
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-3585
Practice Address - Country:US
Practice Address - Phone:309-303-0716
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-05
Last Update Date:2009-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.011334111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor