Healthcare Provider Details

I. General information

NPI: 1619370335
Provider Name (Legal Business Name): WENDI WYLIE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2014
Last Update Date: 10/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1091 PARK DR SUITE B
WATKINSVILLE GA
30677-2014
US

IV. Provider business mailing address

1091 PARK DR SUITE B
WATKINSVILLE GA
30677-2014
US

V. Phone/Fax

Practice location:
  • Phone: 770-207-6390
  • Fax: 678-374-4855
Mailing address:
  • Phone: 770-207-6390
  • Fax: 678-374-4855

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP00333
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: