Provider Demographics
NPI:1629569488
Name:WYATT, AMANDA LEE
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:LEE
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 1:139 DANTLEY DR
Mailing Address - Street 2:
Mailing Address - City:CORBIN
Mailing Address - State:KY
Mailing Address - Zip Code:40701-3102
Mailing Address - Country:US
Mailing Address - Phone:606-224-0136
Mailing Address - Fax:
Practice Address - Street 1:1340 S LAUREL RD
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40744-8304
Practice Address - Country:US
Practice Address - Phone:855-591-0092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-28
Last Update Date:2018-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator