Healthcare Provider Details

I. General information

NPI: 1285739417
Provider Name (Legal Business Name): DAENA C. WILDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 03/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1036 AMBERLEY WAY STE. A
RICHMOND KY
40475-8979
US

IV. Provider business mailing address

1036 AMBERLEY WAY STE. A
RICHMOND KY
40475-8979
US

V. Phone/Fax

Practice location:
  • Phone: 859-623-4458
  • Fax: 859-623-4459
Mailing address:
  • Phone: 859-623-4458
  • Fax: 859-623-4459

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberKY-0136
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number0532
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: