Healthcare Provider Details

I. General information

NPI: 1093658171
Provider Name (Legal Business Name): MYA WILDER
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2026
Last Update Date: 04/13/2026
Certification Date: 04/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1747 W ROOSEVELT RD
CHICAGO IL
60608-1264
US

IV. Provider business mailing address

2522 W LAWRENCE AVE UNIT 257665
CHICAGO IL
60625-8880
US

V. Phone/Fax

Practice location:
  • Phone: 312-355-1203
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: