Provider Demographics
NPI:1740370261
Name:WYATT, FELICIE G (MD)
Entity type:Individual
Prefix:DR
First Name:FELICIE
Middle Name:G
Last Name:WYATT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 22727
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-2727
Mailing Address - Country:US
Mailing Address - Phone:601-200-4644
Mailing Address - Fax:601-200-4645
Practice Address - Street 1:969 LAKELAND DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216
Practice Address - Country:US
Practice Address - Phone:601-200-4644
Practice Address - Fax:601-200-4645
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD.30440207R00000X
MS21128207RG0300X
NE22847207RG0300X
FLME139323207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine