Provider Demographics
NPI:1790183283
Name:WYATT, ROSEMARIE O (NP)
Entity Type:Individual
Prefix:MRS
First Name:ROSEMARIE
Middle Name:O
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 1:120 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-6328
Mailing Address - Country:US
Mailing Address - Phone:910-353-0581
Mailing Address - Fax:910-353-1536
Practice Address - Street 1:120 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-6328
Practice Address - Country:US
Practice Address - Phone:910-353-0581
Practice Address - Fax:910-353-1536
Is Sole Proprietor?:No
Enumeration Date:2014-12-15
Last Update Date:2015-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5007376363LA2200X, 363LG0600X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care