Basic Information
| Provider Information | |||||||||
| NPI: | 1073076931 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WYATT | ||||||||
| FirstName: | MARISSA | ||||||||
| MiddleName: | FAITH | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 22390 | ||||||||
| Address2: | |||||||||
| City: | HOT SPRINGS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 719032390 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8555925265 | ||||||||
| FaxNumber: | 8557591165 | ||||||||
| Practice Location | |||||||||
| Address1: | 1910 MALVERN AVE | ||||||||
| Address2: | |||||||||
| City: | HOT SPRINGS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 71901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5013211000 | ||||||||
| FaxNumber: | 5016202336 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2019 | ||||||||
| LastUpdateDate: | 06/13/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 883594 | TX | N | Nursing Service Providers | Registered Nurse | 367500000X | 120273 | AR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.