Provider Demographics
NPI:1619592672
Name:WYATT, TIERANEY RODRIGUEZ
Entity Type:Individual
Prefix:
First Name:TIERANEY
Middle Name:RODRIGUEZ
Last Name:WYATT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:416 SW 79TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73139-8125
Mailing Address - Country:US
Mailing Address - Phone:918-896-5126
Mailing Address - Fax:
Practice Address - Street 1:416 SW 79TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73139-8125
Practice Address - Country:US
Practice Address - Phone:918-896-5126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-15
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator