Basic Information
| Provider Information | |||||||||
| NPI: | 1134174337 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILDER | ||||||||
| FirstName: | JANICE | ||||||||
| MiddleName: | F | ||||||||
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| Credential: | CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 320 W 10TH AVE | ||||||||
| Address2: | SUITE 106 | ||||||||
| City: | KENNEWICK | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993366302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095865897 | ||||||||
| FaxNumber: | 5095865898 | ||||||||
| Practice Location | |||||||||
| Address1: | 320 W 10TH AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | KENNEWICK | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993366302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095865860 | ||||||||
| FaxNumber: | 5095865120 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | AP30003088 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 9608506 | 05 | WA | MEDICAID |