Healthcare Provider Details

I. General information

NPI: 1154750578
Provider Name (Legal Business Name): CARRIE JEAN WYLLYS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2013
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2845 GREENBRIER RD
GREEN BAY WI
54311-6519
US

IV. Provider business mailing address

PO BOX 735044
CHICAGO IL
60673-5044
US

V. Phone/Fax

Practice location:
  • Phone: 920-288-8000
  • Fax:
Mailing address:
  • Phone: 800-326-2250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
License Number4704260131
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number103627
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704260131
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License NumberCOA.15322-NP
License Number StateOH
# 5
Primary TaxonomyN
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License Number4704260131
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: