Provider Demographics
NPI:1265078794
Name:WYATT, BRIANA (PT, DPT)
Entity type:Individual
Prefix:
First Name:BRIANA
Middle Name:
Last Name:WYATT
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8096 PELICAN RD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33967-3464
Mailing Address - Country:US
Mailing Address - Phone:630-415-4638
Mailing Address - Fax:
Practice Address - Street 1:6870 ALISTER WAY
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4535
Practice Address - Country:US
Practice Address - Phone:239-210-5483
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-19
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL34703225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist