Healthcare Provider Details

I. General information

NPI: 1417997727
Provider Name (Legal Business Name): MARY ANNE WYLIE C.S.-P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 01/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N WOLFE ST
BALTIMORE MD
21287-0005
US

IV. Provider business mailing address

PO BOX 64260
BALTIMORE MD
21264-4260
US

V. Phone/Fax

Practice location:
  • Phone: 410-955-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License NumberR061135
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: