Provider Demographics
NPI:1043784762
Name:WYLIE, KATHLEEN (CFM)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:WYLIE
Suffix:
Gender:F
Credentials:CFM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4252 ARENDELL ST STE C
Mailing Address - Street 2:
Mailing Address - City:MOREHEAD CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28557-0015
Mailing Address - Country:US
Mailing Address - Phone:252-726-8068
Mailing Address - Fax:252-638-4648
Practice Address - Street 1:4252 ARENDELL ST STE C
Practice Address - Street 2:
Practice Address - City:MOREHEAD CITY
Practice Address - State:NC
Practice Address - Zip Code:28557-0015
Practice Address - Country:US
Practice Address - Phone:252-726-8068
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-15
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCCFM03151224900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMastectomy Fitter