Provider Demographics
NPI:1427566678
Name:WYLIE, CHARLY SAMANTHA (CRNA)
Entity Type:Individual
Prefix:
First Name:CHARLY
Middle Name:SAMANTHA
Last Name:WYLIE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1198
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79604-1198
Mailing Address - Country:US
Mailing Address - Phone:325-670-4220
Mailing Address - Fax:325-670-4040
Practice Address - Street 1:205 MARENGO ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:AL
Practice Address - Zip Code:35630-6033
Practice Address - Country:US
Practice Address - Phone:256-768-9191
Practice Address - Fax:256-768-9775
Is Sole Proprietor?:No
Enumeration Date:2018-01-22
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4007302367500000X
AL1-113371367500000X
TX1018723367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered