Healthcare Provider Details

I. General information

NPI: 1053085654
Provider Name (Legal Business Name): BREANNA NICOLE WYLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2021
Last Update Date: 08/06/2021
Certification Date: 08/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3886 HENDERSON DR
JACKSONVILLE NC
28546-5219
US

IV. Provider business mailing address

3886 HENDERSON DR
JACKSONVILLE NC
28546-5219
US

V. Phone/Fax

Practice location:
  • Phone: 910-938-9833
  • Fax: 910-938-9835
Mailing address:
  • Phone: 910-938-9833
  • Fax: 910-938-9835

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberP016593
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: