Provider Demographics
NPI:1487480844
Name:WYATT, ALEXANDRIA AVA
Entity type:Individual
Prefix:
First Name:ALEXANDRIA
Middle Name:AVA
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 1:1667 OCALA LN
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:CA
Mailing Address - Zip Code:92223-3212
Mailing Address - Country:US
Mailing Address - Phone:909-294-9803
Mailing Address - Fax:
Practice Address - Street 1:12810 HEACOCK ST STE B202
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-2873
Practice Address - Country:US
Practice Address - Phone:951-247-6542
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-12
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program