Healthcare Provider Details

I. General information

NPI: 1720475536
Provider Name (Legal Business Name): DENISE WYLIE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2015
Last Update Date: 04/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

365 AVERYVILLE LN
LAKE PLACID NY
12946-3015
US

IV. Provider business mailing address

365 AVERYVILLE LN
LAKE PLACID NY
12946-3015
US

V. Phone/Fax

Practice location:
  • Phone: 518-523-3244
  • Fax:
Mailing address:
  • Phone: 518-523-3244
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: