Healthcare Provider Details

I. General information

NPI: 1093833642
Provider Name (Legal Business Name): PENELOPE WILKE R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5647 U.S. HIGHWAY 26
DUBOIS WY
82513
US

IV. Provider business mailing address

PO BOX 577
DUBOIS WY
82513-0577
US

V. Phone/Fax

Practice location:
  • Phone: 307-455-2516
  • Fax: 307-455-2526
Mailing address:
  • Phone: 307-455-2516
  • Fax: 307-455-2526

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number20407
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: