Provider Demographics
NPI:1184464877
Name:WYATT, KRISTA LEIGHANN
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:LEIGHANN
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 1:840 MAPLE CREEK RD
Mailing Address - Street 2:
Mailing Address - City:RUTHERFORDTON
Mailing Address - State:NC
Mailing Address - Zip Code:28139-8304
Mailing Address - Country:US
Mailing Address - Phone:828-755-4945
Mailing Address - Fax:828-608-0373
Practice Address - Street 1:126 FIDDLERS RUN BLVD
Practice Address - Street 2:
Practice Address - City:MORGANTON
Practice Address - State:NC
Practice Address - Zip Code:28655-7753
Practice Address - Country:US
Practice Address - Phone:828-608-0892
Practice Address - Fax:828-608-0373
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-29
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5020144363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health