Healthcare Provider Details

I. General information

NPI: 1215202130
Provider Name (Legal Business Name): EVELYN WILDER FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2012
Last Update Date: 03/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5821 JAMESON CT
CARMICHAEL CA
95608-0890
US

IV. Provider business mailing address

3012 NOTRE DAME DR
SACRAMENTO CA
95826-3512
US

V. Phone/Fax

Practice location:
  • Phone: 916-486-0411
  • Fax:
Mailing address:
  • Phone: 916-837-1662
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP 20906
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number698623
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: