Provider Demographics
NPI:1083019673
Name:WYLLIE, ELIZABETH (RN)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:WYLLIE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:227 HOWELL ST
Mailing Address - Street 2:
Mailing Address - City:PALMYRA
Mailing Address - State:NY
Mailing Address - Zip Code:14522-1503
Mailing Address - Country:US
Mailing Address - Phone:585-703-2364
Mailing Address - Fax:
Practice Address - Street 1:227 HOWELL ST
Practice Address - Street 2:
Practice Address - City:PALMYRA
Practice Address - State:NY
Practice Address - Zip Code:14522-1503
Practice Address - Country:US
Practice Address - Phone:585-703-2364
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-26
Last Update Date:2014-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY673816-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse