Provider Demographics
NPI:1427008416
Name:WYATT, SUSAN DIANNE (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:DIANNE
Last Name:WYATT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:353 NEW SHACKLE ISLAND RD
Mailing Address - Street 2:SUITE 247C
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37075-2379
Mailing Address - Country:US
Mailing Address - Phone:615-824-5064
Mailing Address - Fax:615-824-0195
Practice Address - Street 1:353 NEW SHACKLE ISLAND RD
Practice Address - Street 2:SUITE 247C
Practice Address - City:HENDERSONVILLE
Practice Address - State:TN
Practice Address - Zip Code:37075-2379
Practice Address - Country:US
Practice Address - Phone:615-824-5064
Practice Address - Fax:615-824-0195
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2010-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN20189207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3048949Medicaid
TN3048949Medicaid
3048949Medicare ID - Type Unspecified