Basic Information
| Provider Information | |||||||||
| NPI: | 1437180312 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILDE | ||||||||
| FirstName: | BARBARA | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | RN, FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1040 MANGROVE AVE | ||||||||
| Address2: | |||||||||
| City: | CHICO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959263509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5303450064 | ||||||||
| FaxNumber: | 5303450080 | ||||||||
| Practice Location | |||||||||
| Address1: | 1040 MANGROVE AVE | ||||||||
| Address2: | |||||||||
| City: | CHICO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959263509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5303450064 | ||||||||
| FaxNumber: | 5303450080 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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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 | 363L00000X | 2266 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | ZZZ15192A | 05 | CA | MEDICAID |