Provider Demographics
NPI:1376241737
Name:WYATT, JENNIFER LAURA (NP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LAURA
Last Name:WYATT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:C
Other - Last Name:WYATT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:1010 PRINCE AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-5805
Mailing Address - Country:US
Mailing Address - Phone:706-425-1470
Mailing Address - Fax:
Practice Address - Street 1:1010 PRINCE AVE STE 300
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-5805
Practice Address - Country:US
Practice Address - Phone:706-425-1470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-15
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN198700363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily