Provider Demographics
NPI:1104585066
Name:WYATT, DONZELLE
Entity type:Individual
Prefix:
First Name:DONZELLE
Middle Name:
Last Name:WYATT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:444 W MANHATTAN BLVD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43608-1025
Mailing Address - Country:US
Mailing Address - Phone:419-984-5924
Mailing Address - Fax:
Practice Address - Street 1:444 W MANHATTAN BLVD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43608-1025
Practice Address - Country:US
Practice Address - Phone:419-984-5924
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-08
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.175877164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse