Provider Demographics
NPI:1275985152
Name:WYATT, MONICA (RN)
Entity type:Individual
Prefix:
First Name:MONICA
Middle Name:
Last Name:WYATT
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:MONICA
Other - Middle Name:
Other - Last Name:WHITESIDE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1060 GAFFNEY RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAINWRIGHT
Mailing Address - State:AK
Mailing Address - Zip Code:99703-5002
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2054 30TH AVE
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-7316
Practice Address - Country:US
Practice Address - Phone:907-455-4555
Practice Address - Fax:833-941-2349
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-05
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK133005363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care