Provider Demographics
NPI:1205981404
Name:WYATT, PAULINE (PT)
Entity type:Individual
Prefix:
First Name:PAULINE
Middle Name:
Last Name:WYATT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:PAULINE
Other - Middle Name:
Other - Last Name:DERRANE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:8259 WICKER AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHN
Mailing Address - State:IN
Mailing Address - Zip Code:46373-8878
Mailing Address - Country:US
Mailing Address - Phone:219-365-6553
Mailing Address - Fax:
Practice Address - Street 1:196 PARKWAY S
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:CT
Practice Address - Zip Code:06385-1234
Practice Address - Country:US
Practice Address - Phone:860-447-0417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT005293225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist