Individual
SHANNON WYATT
Active
Individual
SHANNON WYATT
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
1202213935
VA
332BC3200X
Customized Equipment (DME)
—
—
335E00000X
Prosthetic/Orthotic Supplier
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1202213935
DPOR
VA
Enumeration date
05/05/2016
Last updated
05/06/2016
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