Provider Demographics
NPI:1760994149
Name:WYATT, KEESHA L (NP)
Entity Type:Individual
Prefix:
First Name:KEESHA
Middle Name:L
Last Name:WYATT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KEESHA
Other - Middle Name:L
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:400 W ARBROOK BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76014-3175
Mailing Address - Country:US
Mailing Address - Phone:817-276-6850
Mailing Address - Fax:817-861-4501
Practice Address - Street 1:400 W ARBROOK BLVD STE 100
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76014-3175
Practice Address - Country:US
Practice Address - Phone:817-276-6850
Practice Address - Fax:817-861-4501
Is Sole Proprietor?:No
Enumeration Date:2017-10-25
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP135031363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily