Provider Demographics
NPI:1922414150
Name:WIMBLEY, MYLA
Entity Type:Individual
Prefix:
First Name:MYLA
Middle Name:
Last Name:WIMBLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2255 RENAISSANCE DR STE D
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89119-6750
Mailing Address - Country:US
Mailing Address - Phone:702-222-0660
Mailing Address - Fax:
Practice Address - Street 1:2255 RENAISSANCE DR STE D
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-6750
Practice Address - Country:US
Practice Address - Phone:702-222-0660
Practice Address - Fax:702-222-0689
Is Sole Proprietor?:No
Enumeration Date:2014-07-09
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner