Provider Demographics
NPI:1518178615
Name:WYATT, SALLY MARIE (RN)
Entity Type:Individual
Prefix:MRS
First Name:SALLY
Middle Name:MARIE
Last Name:WYATT
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MRS
Other - First Name:SALLY
Other - Middle Name:MARIE
Other - Last Name:HAMILTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN
Mailing Address - Street 1:217 E OAK ST
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:MN
Mailing Address - Zip Code:56178
Mailing Address - Country:US
Mailing Address - Phone:507-247-3929
Mailing Address - Fax:
Practice Address - Street 1:106 NORTH 4TH AVENUE
Practice Address - Street 2:
Practice Address - City:FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537-1034
Practice Address - Country:US
Practice Address - Phone:218-998-3778
Practice Address - Fax:218-998-3187
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR099619 2163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse