Basic Information
| Provider Information | |||||||||
| NPI: | 1558714857 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WYLLIE | ||||||||
| FirstName: | TORNIA | ||||||||
| MiddleName: | JOVANNA S | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9500 EUCLID AVE # R3 | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441950001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2164445437 | ||||||||
| FaxNumber: | 2166366761 | ||||||||
| Practice Location | |||||||||
| Address1: | 9500 EUCLID AVE # R3 | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441950001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2164445437 | ||||||||
| FaxNumber: | 2166366761 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2016 | ||||||||
| LastUpdateDate: | 09/30/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080A0000X | 35.136256 | OH | Y | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine | 208000000X | 35.136256 | OH | N | Allopathic & Osteopathic Physicians | Pediatrics | 282N00000X | N | Hospitals | General Acute Care Hospital |
No ID Information.