Healthcare Provider Details

I. General information

NPI: 1487706222
Provider Name (Legal Business Name): PHYLLIS WILDER RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2132 MILL CROSSING DR APT 206
VIRGINIA BEACH VA
23454-1263
US

IV. Provider business mailing address

2132 MILL CROSSING DR APT 206
VIRGINIA BEACH VA
23454-1263
US

V. Phone/Fax

Practice location:
  • Phone: 757-961-6592
  • Fax: 757-961-6568
Mailing address:
  • Phone: 757-894-8703
  • Fax: 757-961-6568

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number1-023054
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: