Provider Demographics
NPI:1447590252
Name:WYATT, DIANA LYNN
Entity Type:Individual
Prefix:MS
First Name:DIANA
Middle Name:LYNN
Last Name:WYATT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 APPALACHAIN HWY
Mailing Address - Street 2:
Mailing Address - City:JESSE
Mailing Address - State:WV
Mailing Address - Zip Code:24849-0000
Mailing Address - Country:US
Mailing Address - Phone:304-682-3294
Mailing Address - Fax:
Practice Address - Street 1:122 APPALACHIAN HWY
Practice Address - Street 2:
Practice Address - City:JESSE
Practice Address - State:WV
Practice Address - Zip Code:24849-0000
Practice Address - Country:US
Practice Address - Phone:304-682-3294
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-15
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist