Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LP0200X | Nurse Practitioner - Pediatrics | A003987 | AR |
NPI | 1023448107 |
---|---|
Provider Name | Elizabeth Wyllia |
First Address | Bryant, AR 72022-7525 |
Second Address | Little Rock, AR 72202-3500 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/11/2013 |
Last Update Date | 26/11/2013 |