Provider Demographics
NPI:1992889414
Name:WYATT, MARY M (GNP)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:M
Last Name:WYATT
Suffix:
Gender:F
Credentials:GNP
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Other - First Name:
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Mailing Address - Street 1:12121 RICHMOND AVE
Mailing Address - Street 2:SUITE#409
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77082-2432
Mailing Address - Country:US
Mailing Address - Phone:281-493-4922
Mailing Address - Fax:281-493-9728
Practice Address - Street 1:12121 RICHMOND AVE
Practice Address - Street 2:SUITE#409
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77082-2432
Practice Address - Country:US
Practice Address - Phone:281-493-4922
Practice Address - Fax:281-493-9728
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX456399363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1663882Medicaid
TX1663882Medicaid
TXQ14436Medicare UPIN