Provider Demographics
NPI:1073076931
Name:WYATT, MARISSA FAITH (CRNA)
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:FAITH
Last Name:WYATT
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2424 METFIELD DR APT 2308
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-5306
Mailing Address - Country:US
Mailing Address - Phone:409-920-5534
Mailing Address - Fax:
Practice Address - Street 1:13695 US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:SEBASTIAN
Practice Address - State:FL
Practice Address - Zip Code:32958-3230
Practice Address - Country:US
Practice Address - Phone:772-589-3186
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-08
Last Update Date:2023-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX883594163W00000X
AR120273367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse