Provider Demographics
NPI:1154764587
Name:WYATT, MELANIE L (PTA)
Entity type:Individual
Prefix:
First Name:MELANIE
Middle Name:L
Last Name:WYATT
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:242 PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:ANTRIM
Mailing Address - State:NH
Mailing Address - Zip Code:03440-3407
Mailing Address - Country:US
Mailing Address - Phone:603-731-3459
Mailing Address - Fax:
Practice Address - Street 1:71 ELM ST
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:NH
Practice Address - Zip Code:03055-4810
Practice Address - Country:US
Practice Address - Phone:603-673-2907
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-16
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1083172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker