1275985152 NPI number — MONICA WYATT RN

Table of content: MONICA WYATT RN (NPI 1275985152)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275985152 NPI number — MONICA WYATT RN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WYATT
Provider First Name:
MONICA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WHITESIDE
Provider Other First Name:
MONICA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1275985152
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/26/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1060 GAFFNEY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WAINWRIGHT
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99703-5002
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2054 30TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAIRBANKS
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99701-7316
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-455-4555
Provider Business Practice Location Address Fax Number:
833-941-2349
Provider Enumeration Date:
07/05/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP2300X , with the licence number:  133005 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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