Provider Demographics
NPI:1073076931
Name:WYATT, MARISSA FAITH (CRNA)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:FAITH
Last Name:WYATT
Suffix:
Gender:
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13695 US HIGHWAY 1
Mailing Address - Street 2:
Mailing Address - City:SEBASTIAN
Mailing Address - State:FL
Mailing Address - Zip Code:32958-3230
Mailing Address - Country:US
Mailing Address - Phone:772-589-3196
Mailing Address - Fax:321-843-2196
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:772-589-3196
Practice Address - Fax:321-843-2196
Is Sole Proprietor?:No
Enumeration Date:2019-04-08
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX883594163W00000X
AR120273367500000X
FLAPRN11014736367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL117204000Medicaid