Basic Information
| Provider Information | |||||||||
| NPI: | 1477846855 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WYLLIE | ||||||||
| FirstName: | BENJAMIN | ||||||||
| MiddleName: | EDWARD | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8090 WINDING WAY CT | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221532433 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 8090 WINDING WAY CT | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221532433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038451500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2011 | ||||||||
| LastUpdateDate: | 10/20/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 0024165373 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.