Healthcare Provider Details

I. General information

NPI: 1427703776
Provider Name (Legal Business Name): ALISA SUE WYLIE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2022
Last Update Date: 02/15/2022
Certification Date: 02/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 VICKI LN
NORFOLK NE
68701-4558
US

IV. Provider business mailing address

900 W NORFOLK AVE STE 200
NORFOLK NE
68701-5006
US

V. Phone/Fax

Practice location:
  • Phone: 402-347-4252
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number27100
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: