Provider Demographics
NPI:1790449072
Name:WYATT, KRYSTA DAWN (DACM, LAC DIPLOM)
Entity Type:Individual
Prefix:
First Name:KRYSTA
Middle Name:DAWN
Last Name:WYATT
Suffix:
Gender:F
Credentials:DACM, LAC DIPLOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:231 FULTON ST
Mailing Address - Street 2:
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94062-1316
Mailing Address - Country:US
Mailing Address - Phone:216-526-9066
Mailing Address - Fax:
Practice Address - Street 1:1336 EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:SAN CARLOS
Practice Address - State:CA
Practice Address - Zip Code:94070-5005
Practice Address - Country:US
Practice Address - Phone:650-596-5616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-23
Last Update Date:2021-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19062171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty