Healthcare Provider Details

I. General information

NPI: 1033818331
Provider Name (Legal Business Name): EBONI RENEE WYLLIE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2023
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 W 60TH ST
NEW YORK NY
10023-7905
US

IV. Provider business mailing address

15 RIDGLEY ST
HACKETTSTOWN NJ
07840-3452
US

V. Phone/Fax

Practice location:
  • Phone: 212-227-6100
  • Fax:
Mailing address:
  • Phone: 347-668-5351
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number407883
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number26NJ15081700
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number383395
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: