Provider Demographics
NPI:1952005647
Name:WYATT, MADISON
Entity type:Individual
Prefix:
First Name:MADISON
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 1:26901 BEAUMONT BLVD STE 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:947-522-1848
Mailing Address - Fax:947-522-0307
Practice Address - Street 1:1777 AXTELL DR STE 202
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-4435
Practice Address - Country:US
Practice Address - Phone:248-594-3148
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-28
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered