Provider Demographics
NPI:1770157976
Name:WYLLIE, BRENDA AGATHA
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:AGATHA
Last Name:WYLLIE
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 1:1516 ORIENTAL BLVD
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-2328
Mailing Address - Country:US
Mailing Address - Phone:718-368-7708
Mailing Address - Fax:
Practice Address - Street 1:1516 ORIENTAL BLVD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-2328
Practice Address - Country:US
Practice Address - Phone:718-646-4441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-13
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY444793163WG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0600XNursing Service ProvidersRegistered NurseGerontology