Healthcare Provider Details

I. General information

NPI: 1710797105
Provider Name (Legal Business Name): SYDNEY WILDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2025
Last Update Date: 01/08/2025
Certification Date: 01/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18511 HIGHLANDER MEDICS ST
FORT BLISS TX
79906-5327
US

IV. Provider business mailing address

5119 ARENA DR
LAS CRUCES NM
88012-0664
US

V. Phone/Fax

Practice location:
  • Phone: 540-931-1159
  • Fax:
Mailing address:
  • Phone: 540-931-1159
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License NumberOT-2024-0016
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: