Provider Demographics
NPI:1952062796
Name:WYATT, CHRISTY J (LPN)
Entity Type:Individual
Prefix:
First Name:CHRISTY
Middle Name:J
Last Name:WYATT
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9181 E KEMPER RD
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:OH
Mailing Address - Zip Code:45249-2707
Mailing Address - Country:US
Mailing Address - Phone:513-972-0512
Mailing Address - Fax:
Practice Address - Street 1:9181 E KEMPER RD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:OH
Practice Address - Zip Code:45249-2707
Practice Address - Country:US
Practice Address - Phone:513-972-0512
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-04
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH180685164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0380779Medicaid