Healthcare Provider Details

I. General information

NPI: 1972946713
Provider Name (Legal Business Name): JACQUELINE H WYLAM AUD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2013
Last Update Date: 07/31/2020
Certification Date: 07/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 RILEY HOSPITAL DR 0860
INDIANAPOLIS IN
46202-5109
US

IV. Provider business mailing address

250 N SHADELAND AVE STE 200
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 317-278-1255
  • Fax: 317-278-3743
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number23001958A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: