Provider Demographics
NPI:1649358847
Name:WYATT, LACEY SHAYANN (APN)
Entity type:Individual
Prefix:MRS
First Name:LACEY
Middle Name:SHAYANN
Last Name:WYATT
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1707 LINWOOD DR STE A
Mailing Address - Street 2:
Mailing Address - City:PARAGOULD
Mailing Address - State:AR
Mailing Address - Zip Code:72450-5365
Mailing Address - Country:US
Mailing Address - Phone:870-236-2202
Mailing Address - Fax:
Practice Address - Street 1:1707 LINWOOD DR STE A
Practice Address - Street 2:
Practice Address - City:PARAGOULD
Practice Address - State:AR
Practice Address - Zip Code:72450
Practice Address - Country:US
Practice Address - Phone:870-236-2202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000014041363LF0000X
ARA01865363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3345732OtherMEDICARE-TN
TN1514445Medicaid
AR160259758Medicaid
AR5Y674Medicare PIN