Healthcare Provider Details

I. General information

NPI: 1144748351
Provider Name (Legal Business Name): KASANDRA LEE WYLIN FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

69111 N FOREST AVE
RICHMOND MI
48062-1521
US

IV. Provider business mailing address

69111 N. FOREST AVE
RICHMOND MI
48062
US

V. Phone/Fax

Practice location:
  • Phone: 586-625-2798
  • Fax:
Mailing address:
  • Phone: 586-625-2798
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704232307
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: