Provider Demographics
NPI:1497206361
Name:WYATT, MIA (CNM)
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:
Last Name:WYATT
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10257 MINION CT
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30022-6320
Mailing Address - Country:US
Mailing Address - Phone:773-620-6697
Mailing Address - Fax:
Practice Address - Street 1:5185 PEACHTREE PKWY STE 300
Practice Address - Street 2:
Practice Address - City:PEACHTREE CORNERS
Practice Address - State:GA
Practice Address - Zip Code:30092-6543
Practice Address - Country:US
Practice Address - Phone:770-766-3090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-17
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN262082363LW0102X, 363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health