Provider Demographics
NPI:1710383732
Name:WILEY-SUDDARTH, BRENDA ELIZABETH
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:ELIZABETH
Last Name:WILEY-SUDDARTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BRENDA
Other - Middle Name:ELIZABETH
Other - Last Name:WILEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:REGISTERED NURSE
Mailing Address - Street 1:13101 ALLEN RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHGATE
Mailing Address - State:MI
Mailing Address - Zip Code:48195-2216
Mailing Address - Country:US
Mailing Address - Phone:734-785-7700
Mailing Address - Fax:
Practice Address - Street 1:13101 ALLEN RD
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-2216
Practice Address - Country:US
Practice Address - Phone:734-785-7700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-18
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704199770163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health