Basic Information
| Provider Information | |||||||||
| NPI: | 1730751314 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WYLIE | ||||||||
| FirstName: | CAMERON | ||||||||
| MiddleName: | SUSANNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2112 BOLL ST APT 237 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752042848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9729892334 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1305 N MARTIN AVE | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857210001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5206266154 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2021 | ||||||||
| LastUpdateDate: | 07/13/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 23704103 | TX | Y | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 23704103 | 01 | TX | TEXAS BOARD OF NURSING | OTHER |