Provider Demographics
NPI:1861222143
Name:WYATT, STACY
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
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 1:4801 WOODWAY DR STE 306W
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77056-1828
Mailing Address - Country:US
Mailing Address - Phone:832-225-3345
Mailing Address - Fax:713-583-1504
Practice Address - Street 1:4801 WOODWAY DR STE 306W
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77056-1828
Practice Address - Country:US
Practice Address - Phone:832-225-3345
Practice Address - Fax:713-583-1504
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-02
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1158846363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health