Provider Demographics
NPI:1588001358
Name:WYLLIE, BENNETT MICAH
Entity Type:Individual
Prefix:DR
First Name:BENNETT
Middle Name:MICAH
Last Name:WYLLIE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 NW ENGLEWOOD CT
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GLADSTONE
Mailing Address - State:MO
Mailing Address - Zip Code:64118-4072
Mailing Address - Country:US
Mailing Address - Phone:816-454-5433
Mailing Address - Fax:816-454-8455
Practice Address - Street 1:305 NW ENGLEWOOD CT
Practice Address - Street 2:SUITE 200
Practice Address - City:GLADSTONE
Practice Address - State:MO
Practice Address - Zip Code:64118-4072
Practice Address - Country:US
Practice Address - Phone:816-454-5433
Practice Address - Fax:816-454-8455
Is Sole Proprietor?:No
Enumeration Date:2013-06-03
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013013255111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor