Healthcare Provider Details

I. General information

NPI: 1083735443
Provider Name (Legal Business Name): MELANIE ANN WYLIE RN MSN CNS APN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 08/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 N 64TH ST
BELLEVILLE IL
62223-3809
US

IV. Provider business mailing address

29 FOXMOOR DR
MARYVILLE IL
62062-6729
US

V. Phone/Fax

Practice location:
  • Phone: 618-397-7145
  • Fax: 618-397-0093
Mailing address:
  • Phone: 618-344-8986
  • Fax: 618-397-4368

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number309002368
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: