Provider Demographics
NPI:1376630814
Name:WYLIE, CONSTANCE RUTH
Entity Type:Individual
Prefix:MS
First Name:CONSTANCE
Middle Name:RUTH
Last Name:WYLIE
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:CONNIE
Other - Middle Name:RUTH
Other - Last Name:WYLIE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:FNP
Mailing Address - Street 1:21300 BALD RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:PENN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95946-9402
Mailing Address - Country:US
Mailing Address - Phone:530-304-9606
Mailing Address - Fax:
Practice Address - Street 1:1100 VAN NESS AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94109-6978
Practice Address - Country:US
Practice Address - Phone:415-600-1010
Practice Address - Fax:415-558-7051
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2022-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP7089363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner