Provider Demographics
NPI:1225708670
Name:DASSIE, WYLIE JEROME IV (APRN)
Entity Type:Individual
Prefix:
First Name:WYLIE
Middle Name:JEROME
Last Name:DASSIE
Suffix:IV
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 EDDY ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-4202
Mailing Address - Country:US
Mailing Address - Phone:401-874-9711
Mailing Address - Fax:
Practice Address - Street 1:350 EDDY ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4202
Practice Address - Country:US
Practice Address - Phone:401-874-9711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-16
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program