Healthcare Provider Details

I. General information

NPI: 1285185231
Provider Name (Legal Business Name): MARCELLA WILDEMAN DNP, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2016
Last Update Date: 05/13/2024
Certification Date: 05/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

916 JACKSON AVE # A
SHERIDAN WY
82801-2708
US

IV. Provider business mailing address

916 JACKSON AVE # A
SHERIDAN WY
82801-2708
US

V. Phone/Fax

Practice location:
  • Phone: 130-767-5555
  • Fax:
Mailing address:
  • Phone: 307-675-5555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP60701532
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number48029
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: