Healthcare Provider Details

I. General information

NPI: 1215643531
Provider Name (Legal Business Name): ROWENA B WYLIE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2023
Last Update Date: 01/30/2023
Certification Date: 01/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1777 TAMIAMI TRL STE 304
PORT CHARLOTTE FL
33948-1083
US

IV. Provider business mailing address

28425 CHINQUAPIN DR APT C
PUNTA GORDA FL
33955-2411
US

V. Phone/Fax

Practice location:
  • Phone: 813-528-7048
  • Fax:
Mailing address:
  • Phone: 193-754-6038
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: