Basic Information
Provider Information | |||||||||
NPI: | 1225570930 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WYATT | ||||||||
FirstName: | CHELSEY | ||||||||
MiddleName: | DIANA | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | ZIMMERMAN | ||||||||
OtherFirstName: | CHELSEY | ||||||||
OtherMiddleName: | DIANA | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 800 S MAIN AVE | ||||||||
Address2: |   | ||||||||
City: | RUGBY | ||||||||
State: | ND | ||||||||
PostalCode: | 583682118 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7017765261 | ||||||||
FaxNumber: | 7017765448 | ||||||||
Practice Location | |||||||||
Address1: | 800 S MAIN AVE | ||||||||
Address2: |   | ||||||||
City: | RUGBY | ||||||||
State: | ND | ||||||||
PostalCode: | 583682118 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7017765261 | ||||||||
FaxNumber: | 7017765448 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/11/2016 | ||||||||
LastUpdateDate: | 02/08/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | R 201735-0 | MN | N |   | Nursing Service Providers | Registered Nurse |   | 163W00000X | 219149-30 | WI | N |   | Nursing Service Providers | Registered Nurse |   | 367500000X | R43972 | ND | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
No ID Information.