Basic Information
| Provider Information | |||||||||
| NPI: | 1871577684 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WYATT | ||||||||
| FirstName: | AMBER | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 187 | ||||||||
| Address2: | |||||||||
| City: | SCOTTS HILL | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383740187 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7316141034 | ||||||||
| FaxNumber: | 7315491011 | ||||||||
| Practice Location | |||||||||
| Address1: | 644 HIGHWAY 114 S | ||||||||
| Address2: | |||||||||
| City: | SCOTTS HILL | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383745023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7319683646 | ||||||||
| FaxNumber: | 7319681870 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2005 | ||||||||
| LastUpdateDate: | 08/11/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 07/17/2007 | ||||||||
| NPIReactivationDate: | 01/30/2008 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP2300X | APN0000008360 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 4069459 | 01 | TN | BLUE CROSS PROVIDER NUMBE | OTHER | 3349547 | 05 | TN | MEDICAID | 4138067 | 01 | TN | BCBS | OTHER |