MEDICARE: PHYLLIS WILDER RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WC0400X	Case Management Registered Nurse	1-023054	AL

General Provider Information

NPI Number	:	1487706222
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHYLLIS WILDER RN

Provider Business Mailing Address
First Line	:	2132 MILL CROSSING DR APT 206
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23454-1263
Country	:	US
Telephone Number	:	757-894-8703
Fax Number	:	757-961-6568

Provider Business Practice Location Address
First Line	:	2132 MILL CROSSING DR APT 206
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23454-1263
Country	:	US
Telephone Number	:	757-961-6592
Fax Number	:	757-961-6568

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/18/2007
Last Update Date	:	07/08/2007

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