Provider Demographics
NPI:1558488635
Name:WYANT, MARY LYNN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:LYNN
Last Name:WYANT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MARY
Other - Middle Name:LYNN
Other - Last Name:WINTERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:315 W WALL ST STE 100
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-5284
Mailing Address - Country:US
Mailing Address - Phone:817-410-2600
Mailing Address - Fax:817-488-6452
Practice Address - Street 1:315 W WALL ST STE 100
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-5284
Practice Address - Country:US
Practice Address - Phone:817-410-2600
Practice Address - Fax:817-488-6452
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ07352084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXD17919Medicare UPIN