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General NPI Number Information
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NPI Number | 1073076931
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Entity Type | Individual
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Provider Name | MARISSA FAITH WYATT CRNA
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Gender | Female
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Dates
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Enumeration Date | 04/08/2019
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Last Update Date | 04/02/2025
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Provider Practice Location Address
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Address Line | 13695 US HIGHWAY 1
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City | SEBASTIAN
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State | FL
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Zip | 32958-3230
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Country | US
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Telephone | 772-589-3196
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Fax | 321-843-2196
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Provider Business Mailing Address
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Address Line | 13695 US HIGHWAY 1
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City | SEBASTIAN
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State | FL
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Zip | 32958-3230
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Country | US
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Telephone | 772-589-3196
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Fax | 321-843-2196
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 883594
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | 120273
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License Number State | AR
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Taxonomy #3
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | APRN11014736
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License Number State | FL
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