Basic Information
Provider Information | |||||||||
NPI: | 1306384250 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WILEY | ||||||||
FirstName: | REGINA | ||||||||
MiddleName: | PHILLIPS | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 222 PERRY HWY | ||||||||
Address2: |   | ||||||||
City: | HAWKINSVILLE | ||||||||
State: | GA | ||||||||
PostalCode: | 310366748 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4787830299 | ||||||||
FaxNumber: | 4787833730 | ||||||||
Practice Location | |||||||||
Address1: | 136 W DYKES ST | ||||||||
Address2: |   | ||||||||
City: | COCHRAN | ||||||||
State: | GA | ||||||||
PostalCode: | 31014 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4782710200 | ||||||||
FaxNumber: | 4789348887 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/10/2017 | ||||||||
LastUpdateDate: | 08/15/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN201982 | GA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.