Healthcare Provider Details

I. General information

NPI: 1992889414
Provider Name (Legal Business Name): MARY M WYATT GNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12121 RICHMOND AVE SUITE#409
HOUSTON TX
77082-2432
US

IV. Provider business mailing address

12121 RICHMOND AVE SUITE#409
HOUSTON TX
77082-2432
US

V. Phone/Fax

Practice location:
  • Phone: 281-493-4922
  • Fax: 281-493-9728
Mailing address:
  • Phone: 281-493-4922
  • Fax: 281-493-9728

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number456399
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: