Provider Demographics
NPI:1174608939
Name:WYATT, CAROL J (PTA)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:J
Last Name:WYATT
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6189 HIGHWAY 69 S
Mailing Address - Street 2:
Mailing Address - City:BATH SPRINGS
Mailing Address - State:TN
Mailing Address - Zip Code:38311-4473
Mailing Address - Country:US
Mailing Address - Phone:731-549-9852
Mailing Address - Fax:
Practice Address - Street 1:726 KENTUCKY AVE S
Practice Address - Street 2:
Practice Address - City:PARSONS
Practice Address - State:TN
Practice Address - Zip Code:38363-3105
Practice Address - Country:US
Practice Address - Phone:731-847-6371
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2150225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant