Provider Demographics
NPI:1124308754
Name:WYATT, MICHELLE GILLUM (RN)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:GILLUM
Last Name:WYATT
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12000 TIMBERLANE DR
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99515-3324
Mailing Address - Country:US
Mailing Address - Phone:907-727-6070
Mailing Address - Fax:
Practice Address - Street 1:4100 LAKE OTIS PKWY
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5229
Practice Address - Country:US
Practice Address - Phone:907-550-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-26
Last Update Date:2011-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK23503163W00000X, 163WP2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care