| Doctor Name: | SALLY JO WYATT |
| NPI Number: | 1174767412 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | LMP |
| License Number: | MA60083727 |
| Business Practice Address: | 1963 Bethel Rd Se Port Orchard, WA - 983663108 |
| Business Phone Number: | 3608763393 |
| Business Fax Number: | |
| Mailing Address: | Po Box 403, MANCHESTER |
| State: | WA |
| Postal Code: | 983530403 |
| Phone Number: | 3606494106 |
| Fax Number: | |
| NPI Enumeration Date: | 04/30/2009 |
| NPI Last Update Date: | 02/10/2010 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 174400000X |
| License Number: | MA60083727 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | WA |
| Taxonomy Type: | Other Service Providers |
| Taxonomy Classification: | Specialist |
| Taxonomy Specialization: | |
| Taxonomy Definition: | An individual educated and trained in an applied knowledge discipline used in the performance of work at a level requiring knowledge and skills beyond or apart from that provided by a general education or liberal arts degree. |