Provider Demographics
NPI:1033818331
Name:WYLLIE, EBONI RENEE
Entity Type:Individual
Prefix:
First Name:EBONI
Middle Name:RENEE
Last Name:WYLLIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 RIDGLEY ST
Mailing Address - Street 2:
Mailing Address - City:HACKETTSTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07840-3452
Mailing Address - Country:US
Mailing Address - Phone:347-668-5351
Mailing Address - Fax:
Practice Address - Street 1:15 RIDGLEY ST
Practice Address - Street 2:
Practice Address - City:HACKETTSTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07840-3452
Practice Address - Country:US
Practice Address - Phone:347-668-5351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-27
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY383395363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics