Healthcare Provider Details

I. General information

NPI: 1003566118
Provider Name (Legal Business Name): JENNIFER WYLIE MD, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2022
Last Update Date: 03/24/2022
Certification Date: 03/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL CENTER BLVD. SURGERY OUTPATIENT CLINIC 5TH JANEWAY TOWER
WINSTON-SALEM NC
27157
US

IV. Provider business mailing address

1 MEDICAL CENTER BLVD SURGERY OUTPATIENT CLINIC - 5TH JANEWAY TOWER
WINSTON SALEM NC
27157-0001
US

V. Phone/Fax

Practice location:
  • Phone: 336-716-0423
  • Fax:
Mailing address:
  • Phone: 505-702-1166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: