Provider Demographics
NPI:1346401650
Name:WYATT, TRACI L (OPTICIAN)
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:L
Last Name:WYATT
Suffix:
Gender:F
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 W COLT SQUARE DR
Mailing Address - Street 2:SUITE 2
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-2834
Mailing Address - Country:US
Mailing Address - Phone:479-251-9482
Mailing Address - Fax:
Practice Address - Street 1:104 W COLT SQUARE DR
Practice Address - Street 2:SUITE 2
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-2834
Practice Address - Country:US
Practice Address - Phone:479-251-9482
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-19
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARL-920822156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician