Healthcare Provider Details

I. General information

NPI: 1134679806
Provider Name (Legal Business Name): JAMIE NICOLE WILDER APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2016
Last Update Date: 05/09/2023
Certification Date: 05/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 HOSPITAL DR STE 2
BARBOURVILLE KY
40906-7363
US

IV. Provider business mailing address

80 HOSPITAL DR STE 2
BARBOURVILLE KY
40906-7363
US

V. Phone/Fax

Practice location:
  • Phone: 606-545-5500
  • Fax: 606-545-5511
Mailing address:
  • Phone: 606-545-5500
  • Fax: 606-545-5511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number3010435
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3010435
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: