Basic Information
Provider Information | |||||||||
NPI: | 1760651905 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WYANT | ||||||||
FirstName: | DANIELLE | ||||||||
MiddleName: | ADRIANA DUPONT | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DUPONT | ||||||||
OtherFirstName: | DANIELLE | ||||||||
OtherMiddleName: | ADRIANA | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1540 SUNDAY DR | ||||||||
Address2: |   | ||||||||
City: | RALEIGH | ||||||||
State: | NC | ||||||||
PostalCode: | 276076010 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9197823456 | ||||||||
FaxNumber: | 9197831441 | ||||||||
Practice Location | |||||||||
Address1: | 4111 BEN FRANKLIN BLVD | ||||||||
Address2: |   | ||||||||
City: | DURHAM | ||||||||
State: | NC | ||||||||
PostalCode: | 277042141 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9197198834 | ||||||||
FaxNumber: | 9195820528 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/21/2008 | ||||||||
LastUpdateDate: | 12/11/2012 | ||||||||
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 | 208000000X | 127874 | NC | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 2084N0402X | 2008-127874 | NC | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology with Special Qualifications in Child Neurology |
ID Information
ID | Type | State | Issuer | Description | 5909906 | 05 | NC |   | MEDICAID |