Provider Demographics
NPI:1306384250
Name:WILEY, REGINA PHILLIPS (NP)
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:PHILLIPS
Last Name:WILEY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 PERRY HWY
Mailing Address - Street 2:
Mailing Address - City:HAWKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31036-6748
Mailing Address - Country:US
Mailing Address - Phone:478-783-0299
Mailing Address - Fax:478-783-3730
Practice Address - Street 1:136 W DYKES ST
Practice Address - Street 2:
Practice Address - City:COCHRAN
Practice Address - State:GA
Practice Address - Zip Code:31014
Practice Address - Country:US
Practice Address - Phone:478-271-0200
Practice Address - Fax:478-934-8887
Is Sole Proprietor?:No
Enumeration Date:2017-02-10
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN201982363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily