Healthcare Provider Details

I. General information

NPI: 1174846166
Provider Name (Legal Business Name): MARY JANE WILDMAN CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2010
Last Update Date: 08/31/2023
Certification Date: 08/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 NEW SALEM RD SUITE 116
UNIONTOWN PA
15401-8936
US

IV. Provider business mailing address

100 NEW SALEM RD SUITE 116
UNIONTOWN PA
15401-8936
US

V. Phone/Fax

Practice location:
  • Phone: 724-437-0728
  • Fax:
Mailing address:
  • Phone: 724-437-0728
  • Fax: 724-437-0854

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN588934
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License NumberRN588934
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberSP028136
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: