Healthcare Provider Details

I. General information

NPI: 1033190574
Provider Name (Legal Business Name): JENNIFER HANLON-WILDE F.N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER HANLON F.N.P.

II. Dates (important events)

Enumeration Date: 11/10/2005
Last Update Date: 02/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1810 E 19TH ST SUITE 209
THE DALLES OR
97058-3388
US

IV. Provider business mailing address

PO BOX 1520
THE DALLES OR
97058-8003
US

V. Phone/Fax

Practice location:
  • Phone: 541-296-5657
  • Fax:
Mailing address:
  • Phone: 541-296-5657
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number098006694NP
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number098006694RN FNP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: