Provider Demographics
NPI:1619168960
Name:WYATT, MARILYNN PATTEN (PT)
Entity Type:Individual
Prefix:
First Name:MARILYNN
Middle Name:PATTEN
Last Name:WYATT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34800 BOB WILSON DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92134-1098
Mailing Address - Country:US
Mailing Address - Phone:619-532-6459
Mailing Address - Fax:
Practice Address - Street 1:34800 BOB WILSON DR
Practice Address - Street 2:NMCSD
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-1098
Practice Address - Country:US
Practice Address - Phone:619-532-6459
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-01
Last Update Date:2015-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA66882251E1200X
CAEK 62251E1300X
226300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251E1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistErgonomics
No2251E1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistElectrophysiology, Clinical
No226300000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersKinesiotherapist