Healthcare Provider Details

I. General information

NPI: 1619168960
Provider Name (Legal Business Name): MARILYNN PATTEN WYATT PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2007
Last Update Date: 02/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34800 BOB WILSON DR NMCSD
SAN DIEGO CA
92134-1098
US

IV. Provider business mailing address

34800 BOB WILSON DR
SAN DIEGO CA
92134-1098
US

V. Phone/Fax

Practice location:
  • Phone: 619-532-6459
  • Fax:
Mailing address:
  • Phone: 619-532-6459
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251E1200X
TaxonomyErgonomics Physical Therapist
License Number6688
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2251E1300X
TaxonomyClinical Electrophysiology Physical Therapist
License NumberEK 6
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code226300000X
TaxonomyKinesiotherapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: