Provider Demographics
NPI:1528374410
Name:WYATT, ELIZABETH ANN (MA)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:ANN
Last Name:WYATT
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MISS
Other - First Name:ELIZABETH
Other - Middle Name:ANN
Other - Last Name:FLEITZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:945 FOREST ST
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19904-3401
Mailing Address - Country:US
Mailing Address - Phone:302-672-1960
Mailing Address - Fax:302-672-1967
Practice Address - Street 1:945 FOREST ST
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19904-3401
Practice Address - Country:US
Practice Address - Phone:302-672-1960
Practice Address - Fax:302-672-1967
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-30
Last Update Date:2010-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE19695390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program