Healthcare Provider Details

I. General information

NPI: 1538055710
Provider Name (Legal Business Name): MADISON LYNN WYLAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2025
Last Update Date: 08/05/2025
Certification Date: 08/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 HANESTOWN CT STE 151
WINSTON SALEM NC
27103-1749
US

IV. Provider business mailing address

111 HANESTOWN CT STE 151
WINSTON SALEM NC
27103-1749
US

V. Phone/Fax

Practice location:
  • Phone: 336-765-9350
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0010-14818
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: