Provider Demographics
NPI:1669894275
Name:WYATT, JANELL
Entity type:Individual
Prefix:
First Name:JANELL
Middle Name:
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:PO BOX 161
Mailing Address - Street 2:480 NE 4TH STREET
Mailing Address - City:DUFUR
Mailing Address - State:OR
Mailing Address - Zip Code:97021-0161
Mailing Address - Country:US
Mailing Address - Phone:541-604-6094
Mailing Address - Fax:
Practice Address - Street 1:1700 E 19TH ST
Practice Address - Street 2:MCMC PHYSICAL THERAPY DEPT./ M-POWER REHAB
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-3317
Practice Address - Country:US
Practice Address - Phone:541-296-7282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-16
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR009072251N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251N0400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistNeurology