Provider Demographics
NPI:1083735443
Name:WYLIE, MELANIE ANN (RN MSN CNS APN)
Entity Type:Individual
Prefix:MRS
First Name:MELANIE
Middle Name:ANN
Last Name:WYLIE
Suffix:
Gender:F
Credentials:RN MSN CNS APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 FOXMOOR DR
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-6729
Mailing Address - Country:US
Mailing Address - Phone:618-344-8986
Mailing Address - Fax:618-397-4368
Practice Address - Street 1:12 N 64TH ST
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62223-3809
Practice Address - Country:US
Practice Address - Phone:618-397-7145
Practice Address - Fax:618-397-0093
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL309002368163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL041291221OtherRN LICENSE
IL309002368OtherAPN LICENSE
IL041291221OtherRN LICENSE