Provider Demographics
NPI:1477846855
Name:WYLLIE, BENJAMIN EDWARD (NP)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:EDWARD
Last Name:WYLLIE
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8090 WINDING WAY CT
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22153-2433
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8090 WINDING WAY CT
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22153-2433
Practice Address - Country:US
Practice Address - Phone:703-845-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-18
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024165373363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily