Individual
KELLY WYATT
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
4 BYPASS RD STE 104, SALEM, NJ 08079-2053
(610) 619-7460
Mailing address
333 HICKORY AVE, ASTON, PA 19014-1100
(610) 306-1509
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
26NJ00996800
NJ
207RP1001X
Pulmonary Disease Physician
26NJ00996800
NJ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1033756044
—
NJ
Enumeration date
12/09/2019
Last updated
09/07/2021
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