Healthcare Provider Details

I. General information

NPI: 1669618484
Provider Name (Legal Business Name): LINDA ELAINE WYLIE CFNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2008
Last Update Date: 07/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 NEW MEXICO 3
RIBERA NM
87560
US

IV. Provider business mailing address

PO BOX 158 538 N. PASEO DE ONATE
ESPANOLA NM
87532-0158
US

V. Phone/Fax

Practice location:
  • Phone: 575-421-1113
  • Fax: 575-421-2943
Mailing address:
  • Phone: 505-753-7218
  • Fax: 505-753-5815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP00413
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR23726
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: