Healthcare Provider Details

I. General information

NPI: 1902067473
Provider Name (Legal Business Name): ELIZABETH ANNE WILDT R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2008
Last Update Date: 06/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

807 PLEASANT VALLEY RD
WEST BEND WI
53095-9767
US

IV. Provider business mailing address

835 POTTS AVE
GREEN BAY WI
54304-4535
US

V. Phone/Fax

Practice location:
  • Phone: 262-675-6533
  • Fax:
Mailing address:
  • Phone: 920-491-9082
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WX0106X
TaxonomyOccupational Health Registered Nurse
License Number94890-030
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: