Healthcare Provider Details

I. General information

NPI: 1497079511
Provider Name (Legal Business Name): JEAN WILDER NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2010
Last Update Date: 03/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 WARREN ST
LOWELL MA
01852-2216
US

IV. Provider business mailing address

585-597 MERRIMACK STREET
LOWELL MA
01854
US

V. Phone/Fax

Practice location:
  • Phone: 978-322-8500
  • Fax: 978-446-0248
Mailing address:
  • Phone: 978-322-8500
  • Fax: 978-446-0248

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number237180
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: