Provider Demographics
NPI:1942263140
Name:WYLIE, SUSAN C (RD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:C
Last Name:WYLIE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:C
Other - Last Name:WEEKLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:200 HOSPITAL DR
Mailing Address - Street 2:DRIVE
Mailing Address - City:GALAX
Mailing Address - State:VA
Mailing Address - Zip Code:24333-2227
Mailing Address - Country:US
Mailing Address - Phone:276-236-1686
Mailing Address - Fax:
Practice Address - Street 1:200 HOSPITAL DR
Practice Address - Street 2:DRIVE
Practice Address - City:GALAX
Practice Address - State:VA
Practice Address - Zip Code:24333-2227
Practice Address - Country:US
Practice Address - Phone:276-236-1686
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA00W596S41Medicare ID - Type Unspecified