Provider Demographics
NPI:1720120298
Name:WYATT, CELINE ANN (ACNP)
Entity Type:Individual
Prefix:
First Name:CELINE
Middle Name:ANN
Last Name:WYATT
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:CELINE
Other - Middle Name:ANN
Other - Last Name:ROBERTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 603949
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-3949
Mailing Address - Country:US
Mailing Address - Phone:877-498-4490
Mailing Address - Fax:919-350-7687
Practice Address - Street 1:23 SUNNYBROOK RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-1855
Practice Address - Country:US
Practice Address - Phone:919-350-1570
Practice Address - Fax:919-790-0108
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR17970363LA2100X
NC5005905363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
607156012OtherDEPT OF LABOR
CS95AA97381801OtherCAREFIRST
V8140012OtherCAREFIRST
MD041200700Medicaid
V8140012OtherCAREFIRST