Provider Demographics
NPI:1851791446
Name:WYATT, ORLENA
Entity Type:Individual
Prefix:
First Name:ORLENA
Middle Name:
Last Name:WYATT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4865 BILL GARDNER PKWY
Mailing Address - Street 2:
Mailing Address - City:LOCUST GROVE
Mailing Address - State:GA
Mailing Address - Zip Code:30248-3644
Mailing Address - Country:US
Mailing Address - Phone:770-692-0100
Mailing Address - Fax:770-692-6190
Practice Address - Street 1:4865 BILL GARDNER PKWY
Practice Address - Street 2:
Practice Address - City:LOCUST GROVE
Practice Address - State:GA
Practice Address - Zip Code:30248-3644
Practice Address - Country:US
Practice Address - Phone:770-692-0100
Practice Address - Fax:770-692-6190
Is Sole Proprietor?:No
Enumeration Date:2014-09-02
Last Update Date:2014-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN184183163WG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0100XNursing Service ProvidersRegistered NurseGastroenterology