Provider Demographics
NPI:1174747836
Name:WYLIE, WILLANE A (OD)
Entity type:Individual
Prefix:MS
First Name:WILLANE
Middle Name:A
Last Name:WYLIE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:1948 OROVILLE CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28214-2567
Mailing Address - Country:US
Mailing Address - Phone:704-575-6796
Mailing Address - Fax:704-392-3141
Practice Address - Street 1:9820 CALLABRIDGE CT
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28216-7669
Practice Address - Country:US
Practice Address - Phone:704-398-9115
Practice Address - Fax:704-392-3141
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1824152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist