Provider Demographics
NPI:1841640034
Name:WYATT, SHELLIE
Entity type:Individual
Prefix:
First Name:SHELLIE
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 1:7236 JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48091-2912
Mailing Address - Country:US
Mailing Address - Phone:586-383-8044
Mailing Address - Fax:
Practice Address - Street 1:7236 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48091-2912
Practice Address - Country:US
Practice Address - Phone:586-383-8044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-17
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other