Healthcare Provider Details

I. General information

NPI: 1427566678
Provider Name (Legal Business Name): CHARLY SAMANTHA WYLIE CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2018
Last Update Date: 02/19/2025
Certification Date: 02/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 MARENGO ST
FLORENCE AL
35630-6033
US

IV. Provider business mailing address

PO BOX 1198
ABILENE TX
79604-1198
US

V. Phone/Fax

Practice location:
  • Phone: 256-768-9191
  • Fax: 256-768-9775
Mailing address:
  • Phone: 325-670-4220
  • Fax: 325-670-4040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4007302
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1-113371
License Number StateAL
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1018723
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: