MEDICARE: SHANIQUE 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	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1760855944
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANIQUE WILDER

Provider Business Mailing Address
First Line	:	12601 N PENNSYLVANIA AVE APT 279
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73120-9408
Country	:	US
Telephone Number	:	405-824-3336
Fax Number	:

Provider Business Practice Location Address
First Line	:	12601 N PENNSYLVANIA AVE APT 279
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73120-9408
Country	:	US
Telephone Number	:	405-824-3336
Fax Number	:

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

Provider Enumeration Date	:	11/10/2015
Last Update Date	:	11/10/2015

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Directions to “ SHANIQUE WILDER ” Practice Location

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