Healthcare Provider Details

I. General information

NPI: 1245169424
Provider Name (Legal Business Name): SIERRA WILDMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2026
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 WREN LN
HOWARDS GROVE WI
53083-1485
US

IV. Provider business mailing address

703 WREN LN
HOWARDS GROVE WI
53083-1485
US

V. Phone/Fax

Practice location:
  • Phone: 920-627-0622
  • Fax: 920-627-0622
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number1749033
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: