Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225400000X | Rehabilitation Practitioner |
NPI | 1043555048 |
---|---|
Provider Name | Antwoinnett Wiley |
First Address | North Las Vegas, NV 89030-3787 |
Second Address | North Las Vegas, NV 89030-3787 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 01/12/2012 |
Last Update Date | 01/12/2012 |