Healthcare Provider Details

I. General information

NPI: 1245720580
Provider Name (Legal Business Name): MRS. JANE ANN WYLIE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2018
Last Update Date: 05/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 S SERVICE RD
DIX HILLS NY
11746-6015
US

IV. Provider business mailing address

5 GARDEN AVE
LAKE RONKONKOMA NY
11779-1711
US

V. Phone/Fax

Practice location:
  • Phone: 631-271-0777
  • Fax:
Mailing address:
  • Phone: 631-806-3091
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number5662941111
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: