Provider Demographics
NPI:1336780592
Name:WYANT, KATRINA (DC)
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:
Last Name:WYANT
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:94220A HOLDENBURY DR
Mailing Address - Street 2:
Mailing Address - City:FORT DRUM
Mailing Address - State:NY
Mailing Address - Zip Code:13603-3269
Mailing Address - Country:US
Mailing Address - Phone:315-577-2779
Mailing Address - Fax:
Practice Address - Street 1:1155 COFFEEN ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-1843
Practice Address - Country:US
Practice Address - Phone:315-782-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-30
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013282111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor