Healthcare Provider Details

I. General information

NPI: 1063351245
Provider Name (Legal Business Name): WYLIE BARHAM CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2026
Last Update Date: 03/25/2026
Certification Date: 03/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

748 BAYOU PINES EAST DR STE C
LAKE CHARLES LA
70601-7596
US

IV. Provider business mailing address

748 BAYOU PINES EAST DR STE C
LAKE CHARLES LA
70601-7596
US

V. Phone/Fax

Practice location:
  • Phone: 337-602-1462
  • Fax:
Mailing address:
  • Phone: 337-602-1462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number245658
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: