1356600795 NPI number — MS. NANCY LYNN WYATT PTA

Table of content: MS. NANCY LYNN WYATT PTA (NPI 1356600795)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356600795 NPI number — MS. NANCY LYNN WYATT PTA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WYATT
Provider First Name:
NANCY
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PTA
Provider Gender Code:
F

Provider's Other Name Information

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

NPI Number Information

NPI Number:
1356600795
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/04/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
115 BLARNEY DRIVE
Provider Second Line Business Mailing Address:
SUITE #202 COLUMBIA REHAB. CLINIC, INC.
Provider Business Mailing Address City Name:
COLUMBIA
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29223
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-736-4845
Provider Business Mailing Address Fax Number:
803-736-8674

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
115 BLARNEY DRIVE
Provider Second Line Business Practice Location Address:
SUITE #202
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29223
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-736-4845
Provider Business Practice Location Address Fax Number:
803-736-8674
Provider Enumeration Date:
05/04/2012

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: 225200000X , with the licence number:  114 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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