Healthcare Provider Details

I. General information

NPI: 1538834841
Provider Name (Legal Business Name): TAYLOR WYLIE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2021
Last Update Date: 07/08/2025
Certification Date: 07/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 NW 5TH ST STE D
MOORE OK
73160-3947
US

IV. Provider business mailing address

1005 VALLEY CT
EDMOND OK
73012-6721
US

V. Phone/Fax

Practice location:
  • Phone: 405-208-4469
  • Fax:
Mailing address:
  • Phone: 228-229-9029
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number21688-P
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: