Provider Demographics
NPI:1821286519
Name:WYATT, BROOKE MARY (PA)
Entity Type:Individual
Prefix:MS
First Name:BROOKE
Middle Name:MARY
Last Name:WYATT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1645 S MAIN ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CROSSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38555-2908
Mailing Address - Country:US
Mailing Address - Phone:931-484-7531
Mailing Address - Fax:931-456-9515
Practice Address - Street 1:1645 S MAIN ST
Practice Address - Street 2:SUITE 101
Practice Address - City:CROSSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38555-2908
Practice Address - Country:US
Practice Address - Phone:931-484-7531
Practice Address - Fax:931-456-9515
Is Sole Proprietor?:No
Enumeration Date:2007-10-09
Last Update Date:2014-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1544363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1512162Medicaid
TN4224896OtherBCBS
TN1512162Medicaid