Provider Demographics
NPI:1194797712
Name:WILEY, ELIZABETH J (FNP)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:J
Last Name:WILEY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4101 WESLEY ST STE C
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75401-5635
Mailing Address - Country:US
Mailing Address - Phone:903-454-8111
Mailing Address - Fax:903-454-1680
Practice Address - Street 1:4101 WESLEY ST STE C
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:TX
Practice Address - Zip Code:75401-5635
Practice Address - Country:US
Practice Address - Phone:903-454-8111
Practice Address - Fax:903-454-1680
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX660449363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8N9409OtherBCBS OF TEXAS
TX177443201Medicaid
TX177443203Medicaid
TX177443202Medicaid
TX177443204Medicaid
TXP00315230OtherRAILROAD MEDICARE
TX177443204Medicaid
TXD9503Medicare ID - Type Unspecified
TXTXB114167Medicare PIN
TXTXB114178Medicare PIN
TXTXB114149Medicare PIN