Provider Demographics
NPI:1750509717
Name:WYATT, ALICE F (NP)
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:F
Last Name:WYATT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:KULBERSH WOMEN'S CENTER
Mailing Address - Street 2:ONE WELLNESS BLVD. SUITE 203
Mailing Address - City:IRMO
Mailing Address - State:SC
Mailing Address - Zip Code:29063
Mailing Address - Country:US
Mailing Address - Phone:803-732-4608
Mailing Address - Fax:803-732-4692
Practice Address - Street 1:ONE WELLNESS BLVD.
Practice Address - Street 2:SUITE 203
Practice Address - City:IRMO
Practice Address - State:SC
Practice Address - Zip Code:29063
Practice Address - Country:US
Practice Address - Phone:803-732-4608
Practice Address - Fax:803-732-4692
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCAPN 336163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCMW0132756OtherDEA