Healthcare Provider Details

I. General information

NPI: 1679951487
Provider Name (Legal Business Name): KATHRYN ELIZABETH WILDE WHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2015
Last Update Date: 04/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6071 E WOODMEN RD SUITE 405
COLORADO SPRINGS CO
80923-2614
US

IV. Provider business mailing address

6071 E WOODMEN RD SUITE 405
COLORADO SPRINGS CO
80923-2614
US

V. Phone/Fax

Practice location:
  • Phone: 719-442-0808
  • Fax: 719-622-3400
Mailing address:
  • Phone: 719-442-0808
  • Fax: 719-622-3400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number0991565
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: