Provider Demographics
NPI:1790787315
Name:WOOD, WYETHA S (ARNP, BC, MSN)
Entity Type:Individual
Prefix:
First Name:WYETHA
Middle Name:S
Last Name:WOOD
Suffix:
Gender:F
Credentials:ARNP, BC, MSN
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 4156
Mailing Address - Street 2:
Mailing Address - City:HOPKINSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42241-4156
Mailing Address - Country:US
Mailing Address - Phone:270-886-2205
Mailing Address - Fax:270-886-0392
Practice Address - Street 1:310 HAWTHORNE ST
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:KY
Practice Address - Zip Code:42445-1622
Practice Address - Country:US
Practice Address - Phone:270-365-0227
Practice Address - Fax:270-365-2559
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2014-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2152P363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78215209Medicaid
000000505347OtherBLUE CROSS
KYK128960Medicare PIN
000000505347OtherBLUE CROSS
KY78215209Medicaid
KY00193002Medicare PIN
KY1276107Medicare PIN