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General NPI Number Information
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NPI Number | 1639113376
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Entity Type | Individual
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Provider Name | MICHELLE WILDER PT
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Gender | Female
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Dates
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Enumeration Date | 06/15/2006
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Last Update Date | 12/16/2020
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Provider Practice Location Address
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Address Line | 2400 EASTPOINT PKWY STE 130
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City | LOUISVILLE
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State | KY
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Zip | 40223-4154
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Country | US
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Telephone | 502-962-2400
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Fax |
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Provider Business Mailing Address
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Address Line | 14007 HICKORY RIDGE RD
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City | LOUISVILLE
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State | KY
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Zip | 40245-5176
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Country | US
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Telephone | 502-777-2965
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Fax | 502-742-5553
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 003773
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License Number State | KY
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