Basic Information
| Provider Information | |||||||||
| NPI: | 1164917787 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILDERN | ||||||||
| FirstName: | WENDY | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 13008 | ||||||||
| Address2: | |||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489013008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5172536320 | ||||||||
| FaxNumber: | 5172536321 | ||||||||
| Practice Location | |||||||||
| Address1: | 1215 E MICHIGAN AVE FL 7 | ||||||||
| Address2: | |||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489121811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173643380 | ||||||||
| FaxNumber: | 5173643399 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2018 | ||||||||
| LastUpdateDate: | 06/26/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 4704250298 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.