MEDICARE: TAMIKO WILDER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	305006-031	WI

General Provider Information

NPI Number	:	1053614982
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAMIKO WILDER

Provider Business Mailing Address
First Line	:	2973 N 56TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53210-1528
Country	:	US
Telephone Number	:	414-837-3904
Fax Number	:

Provider Business Practice Location Address
First Line	:	2973 N 56TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53210-1528
Country	:	US
Telephone Number	:	414-837-3904
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/15/2010
Last Update Date	:	12/15/2010

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Directions to “ TAMIKO WILDER ” Practice Location

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