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1952897779 NPI number — KELLI RENEE WILDER-OUTLAW NP

NPI Number: 1952897779
Health Care Provider/Practitioner: KELLI RENEE WILDER-OUTLAW NP

Information about “1952897779” NPI (KELLI RENEE WILDER-OUTLAW NP) exists in 1952897779 in HTML format HTML  |  1952897779 in plain Text format TXT  |  1952897779 in PDF (Portable Document Format) PDF  |  1952897779 in an XML format XML  formats.

NPI Number : 1952897779 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1952897779",
    "EntityType": "Individual",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": "N",
    "IsOrgSubpart": null,
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": null,
    "LastName": "WILDER-OUTLAW",
    "FirstName": "KELLI",
    "MiddleName": "RENEE",
    "NamePrefix": null,
    "NameSuffix": null,
    "Credential": "NP",
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": null,
    "OtherFirstName": null,
    "OtherMiddleName": null,
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": null,
    "OtherLastNameTypeCode": null,
    "FirstLineMailingAddress": "3082 WHEELER STATION RD",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "BLOOMFIELD",
    "MailingAddressStateName": "NY",
    "MailingAddressPostalCode": "14469-9215",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "585-746-3335",
    "MailingAddressFaxNumber": null,
    "FirstLinePracticeLocationAddress": "601 ELMWOOD AVE",
    "SecondLinePracticeLocationAddress": null,
    "PracticeLocationAddressCityName": "ROCHESTER",
    "PracticeLocationAddressStateName": "NY",
    "PracticeLocationAddressPostalCode": "14642-0001",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "585-275-6026",
    "PracticeLocationAddressFaxNumber": null,
    "EnumerationDate": "07/04/2018",
    "LastUpdateDate": "06/30/2023",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": "F",
    "Gender": "Female",
    "AuthorizedOfficialLastName": null,
    "AuthorizedOfficialFirstName": null,
    "AuthorizedOfficialMiddleName": null,
    "AuthorizedOfficialTitle": null,
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": null,
    "AuthorizedOfficialTelephoneNumber": null,
    "Taxonomies": {
      "Taxonomy": [
        {
          "TaxonomyCode": "363LA2100X",
          "TaxonomyName": "Acute Care Nurse Practitioner",
          "LicenseNumber": "F431324",
          "LicenseNumberStateCode": "NY",
          "PrimaryTaxonomySwitch": "Y"
        },
        {
          "TaxonomyCode": "363L00000X",
          "TaxonomyName": "Nurse Practitioner",
          "LicenseNumber": "431324",
          "LicenseNumberStateCode": "NY",
          "PrimaryTaxonomySwitch": "N"
        }
      ]
    },
    "HealthcareProviderTaxonomyGroups": null
  }
}
                
            

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