Provider Demographics
NPI:1457909095
Name:WILEY, NAKETTA JEAN
Entity type:Individual
Prefix:MRS
First Name:NAKETTA
Middle Name:JEAN
Last Name:WILEY
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 1:7709 AMY MARIE CT NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-6543
Mailing Address - Country:US
Mailing Address - Phone:505-604-9408
Mailing Address - Fax:
Practice Address - Street 1:7709 AMY MARIE CT NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87120-6543
Practice Address - Country:US
Practice Address - Phone:505-604-9408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-27
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMBACB545853106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician