Provider Demographics
NPI:1669618484
Name:WYLIE, LINDA ELAINE (CFNP)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:ELAINE
Last Name:WYLIE
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 158
Mailing Address - Street 2:538 N. PASEO DE ONATE
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-0158
Mailing Address - Country:US
Mailing Address - Phone:505-753-7218
Mailing Address - Fax:505-753-5815
Practice Address - Street 1:275 NEW MEXICO 3
Practice Address - Street 2:
Practice Address - City:RIBERA
Practice Address - State:NM
Practice Address - Zip Code:87560
Practice Address - Country:US
Practice Address - Phone:575-421-1113
Practice Address - Fax:575-421-2943
Is Sole Proprietor?:No
Enumeration Date:2008-12-29
Last Update Date:2013-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP00413363LF0000X
NMR23726363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM400316OtherMEDICARE PTAN
NM44256779Medicaid
NMNM400316OtherMEDICARE PTAN