Individual
MYLLISSA M. WYATT
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
NP
Contact information
Practice address
403 RIVERFRONT DR, SALMON, ID 83467-5162
(208) 742-1110
(208) 742-1120
Mailing address
403 RIVERFRONT DR, SALMON, ID 83467-5162
(208) 742-1110
(208) 742-1120
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
1202A
ID
363LF0000X
Family Nurse Practitioner
Primary
NP-1202A
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
IDTPID011077
—
ID
Enumeration date
09/12/2012
Last updated
01/22/2025
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