Provider Demographics
NPI:1619043395
Name:WYATT, CAROL ANN (RN)
Entity Type:Individual
Prefix:MRS
First Name:CAROL
Middle Name:ANN
Last Name:WYATT
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MRS
Other - First Name:CAROL
Other - Middle Name:ANN
Other - Last Name:BYRAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:PO BOX 514
Mailing Address - Street 2:
Mailing Address - City:ESTACADA
Mailing Address - State:OR
Mailing Address - Zip Code:97023-0514
Mailing Address - Country:US
Mailing Address - Phone:503-630-6787
Mailing Address - Fax:503-630-6787
Practice Address - Street 1:402 SE 3RD AVE
Practice Address - Street 2:
Practice Address - City:ESTACADA
Practice Address - State:OR
Practice Address - Zip Code:97023-8563
Practice Address - Country:US
Practice Address - Phone:503-630-6787
Practice Address - Fax:503-630-6787
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2010-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR000032351RN163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR098011Medicaid