Healthcare Provider Details

I. General information

NPI: 1841774585
Provider Name (Legal Business Name): HALEY WILDMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2018
Last Update Date: 03/11/2021
Certification Date: 03/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 E MARKET ST
WARREN OH
44484-2260
US

IV. Provider business mailing address

4169 KINCAID EAST RD NW
WARREN OH
44481-9160
US

V. Phone/Fax

Practice location:
  • Phone: 330-856-9699
  • Fax:
Mailing address:
  • Phone: 330-720-1831
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberAPRN.CNP.023599
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: