Provider Demographics
NPI:1093191819
Name:WYATT, FALLON E
Entity Type:Individual
Prefix:
First Name:FALLON
Middle Name:E
Last Name:WYATT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:FALLON
Other - Middle Name:E
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4001 COMMERCIAL CENTER DR STE 1
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:AR
Mailing Address - Zip Code:72364-9616
Mailing Address - Country:US
Mailing Address - Phone:901-496-0071
Mailing Address - Fax:
Practice Address - Street 1:4001 COMMERCIAL CENTER DR STE 1
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:AR
Practice Address - Zip Code:72364-9616
Practice Address - Country:US
Practice Address - Phone:901-496-0071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-04
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA004461363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily