Healthcare Provider Details

I. General information

NPI: 1457929945
Provider Name (Legal Business Name): JAMIE MARIE WILDER FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2021
Last Update Date: 11/04/2022
Certification Date: 11/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2030 BLUEGRASS CIR
CHEYENNE WY
82009-7328
US

IV. Provider business mailing address

2030 BLUEGRASS CIR
CHEYENNE WY
82009-7328
US

V. Phone/Fax

Practice location:
  • Phone: 307-635-3500
  • Fax:
Mailing address:
  • Phone: 307-635-3500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number50837
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: