Provider Demographics
NPI:1427703776
Name:WYLIE, ALISA SUE
Entity type:Individual
Prefix:
First Name:ALISA
Middle Name:SUE
Last Name:WYLIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 W NORFOLK AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:NE
Mailing Address - Zip Code:68701-5006
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1900 VICKI LN
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:NE
Practice Address - Zip Code:68701-4558
Practice Address - Country:US
Practice Address - Phone:402-347-4252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-15
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE27100164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse