Provider Demographics
NPI:1700565876
Name:WYATT, AMANDA (PMHNP)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:WYATT
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:440 PARADISE LN
Mailing Address - Street 2:
Mailing Address - City:CROSSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38572-2105
Mailing Address - Country:US
Mailing Address - Phone:931-510-8405
Mailing Address - Fax:
Practice Address - Street 1:441 E BROAD ST STE E
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-3390
Practice Address - Country:US
Practice Address - Phone:931-510-9231
Practice Address - Fax:207-810-5946
Is Sole Proprietor?:No
Enumeration Date:2023-07-14
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN34282363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health