Healthcare Provider Details

I. General information

NPI: 1174747836
Provider Name (Legal Business Name): WILLANE A. WYLIE O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9820 CALLABRIDGE CT
CHARLOTTE NC
28216-7669
US

IV. Provider business mailing address

1948 OROVILLE CT
CHARLOTTE NC
28214-2567
US

V. Phone/Fax

Practice location:
  • Phone: 704-398-9115
  • Fax: 704-392-3141
Mailing address:
  • Phone: 704-575-6796
  • Fax: 704-392-3141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1824
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: