Healthcare Provider Details

I. General information

NPI: 1861765331
Provider Name (Legal Business Name): CHRISTINE ANN WILD A.N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2012
Last Update Date: 04/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 MAIN ST
OLEAN NY
14760-1500
US

IV. Provider business mailing address

535 MAIN ST
OLEAN NY
14760-1500
US

V. Phone/Fax

Practice location:
  • Phone: 716-372-0141
  • Fax: 716-372-6421
Mailing address:
  • Phone: 716-372-0141
  • Fax: 716-372-6421

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number305970
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: