Provider Demographics
NPI:1174767412
Name:WYATT, SALLY JO (LMP)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:JO
Last Name:WYATT
Suffix:
Gender:F
Credentials:LMP
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 403
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:WA
Mailing Address - Zip Code:98353-0403
Mailing Address - Country:US
Mailing Address - Phone:360-649-4106
Mailing Address - Fax:
Practice Address - Street 1:1963 BETHEL RD SE
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-3108
Practice Address - Country:US
Practice Address - Phone:360-876-3393
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-30
Last Update Date:2010-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60083727174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist