Provider Demographics
NPI:1730439266
Name:WYATT, MYLLISSA M (NP)
Entity type:Individual
Prefix:
First Name:MYLLISSA
Middle Name:M
Last Name:WYATT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MYLLISSA
Other - Middle Name:M
Other - Last Name:PENA-WYATT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:403 RIVERFRONT DR
Mailing Address - Street 2:
Mailing Address - City:SALMON
Mailing Address - State:ID
Mailing Address - Zip Code:83467-5162
Mailing Address - Country:US
Mailing Address - Phone:208-742-1110
Mailing Address - Fax:208-742-1120
Practice Address - Street 1:403 RIVERFRONT DR
Practice Address - Street 2:
Practice Address - City:SALMON
Practice Address - State:ID
Practice Address - Zip Code:83467-5162
Practice Address - Country:US
Practice Address - Phone:208-742-1110
Practice Address - Fax:208-742-1120
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-12
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP-1202A363LF0000X
ID1202A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDIDTPID011077Medicaid