Provider Demographics
NPI:1033659792
Name:WYLIE, LINZY ANN (ASSOCIATE DEGREE)
Entity type:Individual
Prefix:
First Name:LINZY
Middle Name:ANN
Last Name:WYLIE
Suffix:
Gender:F
Credentials:ASSOCIATE DEGREE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:507 DEWEY AVE
Mailing Address - Street 2:
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953-4215
Mailing Address - Country:US
Mailing Address - Phone:918-649-0172
Mailing Address - Fax:
Practice Address - Street 1:507 DEWEY AVE
Practice Address - Street 2:
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-4215
Practice Address - Country:US
Practice Address - Phone:918-649-0172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-28
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKT083164340171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator