Provider Demographics
NPI:1912740366
Name:WYATT, KASSIDY KAYE (RN)
Entity type:Individual
Prefix:
First Name:KASSIDY
Middle Name:KAYE
Last Name:WYATT
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:KASSIDY
Other - Middle Name:KAYE
Other - Last Name:HAYES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1215 ALDRICH WAY
Mailing Address - Street 2:
Mailing Address - City:FARIBAULT
Mailing Address - State:MN
Mailing Address - Zip Code:55021-7031
Mailing Address - Country:US
Mailing Address - Phone:760-960-8301
Mailing Address - Fax:
Practice Address - Street 1:1215 ALDRICH WAY
Practice Address - Street 2:
Practice Address - City:FARIBAULT
Practice Address - State:MN
Practice Address - Zip Code:55021-7031
Practice Address - Country:US
Practice Address - Phone:760-960-8301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-14
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2301781163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WH0200XNursing Service ProvidersRegistered NurseHome HealthGroup - Single Specialty