1669618484 NPI number — LINDA ELAINE WYLIE CFNP

Table of content: LINDA ELAINE WYLIE CFNP (NPI 1669618484)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669618484 NPI number — LINDA ELAINE WYLIE CFNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WYLIE
Provider First Name:
LINDA
Provider Middle Name:
ELAINE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CFNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1669618484
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/05/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 158
Provider Second Line Business Mailing Address:
538 N. PASEO DE ONATE
Provider Business Mailing Address City Name:
ESPANOLA
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87532-0158
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-753-7218
Provider Business Mailing Address Fax Number:
505-753-5815

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
275 NEW MEXICO 3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIBERA
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87560
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-421-1113
Provider Business Practice Location Address Fax Number:
575-421-2943
Provider Enumeration Date:
12/29/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  CNP00413 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LF0000X , with the licence number: R23726 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: NM400316 . This is a "MEDICARE PTAN" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 44256779 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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