Provider Demographics
NPI:1114288891
Name:WYATT, KATIE MARIE (NP-C)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:MARIE
Last Name:WYATT
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:496 SHOUP AVE W
Mailing Address - Street 2:SUITE E
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-5834
Mailing Address - Country:US
Mailing Address - Phone:208-733-2885
Mailing Address - Fax:208-734-3352
Practice Address - Street 1:496 SHOUP AVE W
Practice Address - Street 2:SUITE E
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5834
Practice Address - Country:US
Practice Address - Phone:208-733-2885
Practice Address - Fax:208-734-3352
Is Sole Proprietor?:No
Enumeration Date:2012-05-30
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP-1196A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1114288891Medicare PIN