Healthcare Provider Details

I. General information

NPI: 1891626529
Provider Name (Legal Business Name): ELIZABETH WYLLIE AUD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2026
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10200 TRINITY PKWY STE 201
STOCKTON CA
95219-7288
US

IV. Provider business mailing address

1111 EXPOSITION BLVD BLDG 700
SACRAMENTO CA
95815-4314
US

V. Phone/Fax

Practice location:
  • Phone: 209-952-0483
  • Fax:
Mailing address:
  • Phone: 916-736-3999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: