Healthcare Provider Details

I. General information

NPI: 1841311446
Provider Name (Legal Business Name): LISA L WILDER N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 02/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 WEST 3RD STREET
COOKEVILLE TN
38503-0938
US

IV. Provider business mailing address

135 WEST 3RD STREET
COOKEVILLE TN
38503-0938
US

V. Phone/Fax

Practice location:
  • Phone: 931-526-2488
  • Fax: 931-526-6332
Mailing address:
  • Phone: 931-526-2488
  • Fax: 931-526-6332

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number12727
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: