Basic Information
Provider Information | |||||||||
NPI: | 1124373121 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WILHELM | ||||||||
FirstName: | DARLENE | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | CNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GOOLEY | ||||||||
OtherFirstName: | DARLENE | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 26666 | ||||||||
Address2: | PHS PROVIDER ENROLLMENT | ||||||||
City: | ALBUQUERQUE | ||||||||
State: | NM | ||||||||
PostalCode: | 871256666 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5059236770 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2702 NAVARRE AVE STE 320 | ||||||||
Address2: |   | ||||||||
City: | OREGON | ||||||||
State: | OH | ||||||||
PostalCode: | 436163224 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4196965555 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/17/2012 | ||||||||
LastUpdateDate: | 02/07/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/07/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 65672 | NM | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 207RG0100X | 13526NP | OH | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
No ID Information.