Provider Demographics
NPI:1992356588
Name:KUYKENDALL, MARISSA ANN (CNM)
Entity type:Individual
Prefix:MRS
First Name:MARISSA
Middle Name:ANN
Last Name:KUYKENDALL
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:MISS
Other - First Name:MARISSA
Other - Middle Name:
Other - Last Name:CANNON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:5323 HARRY HINES BLVD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75390-9032
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:928 N GLENWOOD BLVD
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-5055
Practice Address - Country:US
Practice Address - Phone:903-535-9041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-25
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP143178367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1992356588Medicaid