Healthcare Provider Details

I. General information

NPI: 1770157976
Provider Name (Legal Business Name): BRENDA AGATHA WYLLIE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2021
Last Update Date: 05/13/2021
Certification Date: 05/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1516 ORIENTAL BLVD
BROOKLYN NY
11235-2328
US

IV. Provider business mailing address

1516 ORIENTAL BLVD
BROOKLYN NY
11235-2328
US

V. Phone/Fax

Practice location:
  • Phone: 718-646-4441
  • Fax:
Mailing address:
  • Phone: 718-368-7708
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0600X
TaxonomyGerontology Registered Nurse
License Number444793
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: