Provider Demographics
NPI:1194167882
Name:WYATT, LAUREN TODT (CRNP)
Entity type:Individual
Prefix:MRS
First Name:LAUREN
Middle Name:TODT
Last Name:WYATT
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 699
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:TN
Mailing Address - Zip Code:37684-0699
Mailing Address - Country:US
Mailing Address - Phone:423-431-3950
Mailing Address - Fax:423-431-3958
Practice Address - Street 1:400 N STATE OF FRANKLIN RD FL 1
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-6035
Practice Address - Country:US
Practice Address - Phone:423-431-3950
Practice Address - Fax:423-431-3958
Is Sole Proprietor?:No
Enumeration Date:2013-07-23
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-113979363LP0200X
TNAPN26937363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1-113979Medicaid
TNQ055437Medicaid