Provider Demographics
NPI:1215102959
Name:WYATT, SHARON RENEE
Entity type:Individual
Prefix:
First Name:SHARON
Middle Name:RENEE
Last Name:WYATT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:341 TRANE DR
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37919-6053
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:341 TRANE DR
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37919-6053
Practice Address - Country:US
Practice Address - Phone:865-588-0880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-24
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN88764367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1509614Medicaid