Provider Demographics
NPI:1346419058
Name:LAWRENCE & CHONA WYLIE,M.D.,P.A
Entity Type:Organization
Organization Name:LAWRENCE & CHONA WYLIE,M.D.,P.A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHONA
Authorized Official - Middle Name:DEGRACIA
Authorized Official - Last Name:WYLIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-672-2100
Mailing Address - Street 1:150 S BEACH ST STE A
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174
Mailing Address - Country:US
Mailing Address - Phone:386-672-2100
Mailing Address - Fax:386-672-2135
Practice Address - Street 1:150 S BEACH ST STE A
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174
Practice Address - Country:US
Practice Address - Phone:386-672-2100
Practice Address - Fax:386-672-2135
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-27
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL97096Medicare PIN