Provider Demographics
NPI:1427173814
Name:WYLLIE, MARYELLEN (NP)
Entity type:Individual
Prefix:MS
First Name:MARYELLEN
Middle Name:
Last Name:WYLLIE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 KENSINGTON RD
Mailing Address - Street 2:
Mailing Address - City:RIVER EDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07661-1207
Mailing Address - Country:US
Mailing Address - Phone:201-262-0658
Mailing Address - Fax:
Practice Address - Street 1:NY PRESBYTERIAN HOSPITAL FAMILY PLANNING CLINIC
Practice Address - Street 2:21 AUDOBON AVENUE
Practice Address - City:NYC
Practice Address - State:NY
Practice Address - Zip Code:10032
Practice Address - Country:US
Practice Address - Phone:212-342-3211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYFR300369-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health