Provider Demographics
NPI:1477132462
Name:WYATT, HALEY (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:HALEY
Middle Name:
Last Name:WYATT
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1518 BROWN AVE
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37760-1807
Mailing Address - Country:US
Mailing Address - Phone:740-319-4100
Mailing Address - Fax:
Practice Address - Street 1:1518 BROWN AVE
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37760-1807
Practice Address - Country:US
Practice Address - Phone:740-319-4100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-06
Last Update Date:2022-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN27842255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty