Provider Demographics
NPI:1891845178
Name:WYATT, KENNETH N (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:N
Last Name:WYATT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:648 HARTSVIILE PIKE
Mailing Address - Street 2:
Mailing Address - City:GALLATIN
Mailing Address - State:TN
Mailing Address - Zip Code:37066
Mailing Address - Country:US
Mailing Address - Phone:615-451-9246
Mailing Address - Fax:615-575-5040
Practice Address - Street 1:262 NEW SHACKLE ISLAND RD
Practice Address - Street 2:SUITE 203
Practice Address - City:HENDERSONVILLE
Practice Address - State:TN
Practice Address - Zip Code:37075-2489
Practice Address - Country:US
Practice Address - Phone:615-824-1142
Practice Address - Fax:615-264-3536
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD15478208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNAW9493189OtherDEA
TNA97209Medicare UPIN