=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891626529
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELIZABETH WYLLIE AUD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/29/2026
-----------------------------------------------------
Last Update Date | 05/29/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10200 TRINITY PKWY STE 201
-----------------------------------------------------
City | STOCKTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95219-7288
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-952-0483
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1111 EXPOSITION BLVD BLDG 700
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95815-4314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-736-3999
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 231H00000X
-----------------------------------------------------
Taxonomy Name | Audiologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------