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General NPI Number Information
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NPI Number | 1790379618
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Entity Type | Individual
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Provider Name | MARY WILDEMAN
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Gender | Female
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Dates
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Enumeration Date | 02/22/2021
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Last Update Date | 01/07/2025
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Provider Practice Location Address
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Address Line | 926 MAIN ST
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City | NASHVILLE
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State | TN
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Zip | 37206-3614
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Country | US
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Telephone | 615-436-9060
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Fax | 615-235-9725
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Provider Business Mailing Address
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Address Line | 10400 FAR VIEW DR
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City | EVANSVILLE
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State | IN
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Zip | 47712-8946
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Country | US
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Telephone | 812-306-4757
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Fax |
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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 | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 28203347A
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License Number State | IN
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