Basic Information
| Provider Information | |||||||||
| NPI: | 1689670168 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILDE | ||||||||
| FirstName: | REGINA | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | NURSE PRACTITIONER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1490 UNIVERSITY BLVD | ||||||||
| Address2: | |||||||||
| City: | HAMILTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450113305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5138817189 | ||||||||
| FaxNumber: | 5138817188 | ||||||||
| Practice Location | |||||||||
| Address1: | 1490 UNIVERSITY BLVD | ||||||||
| Address2: | |||||||||
| City: | HAMILTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450113305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5138817189 | ||||||||
| FaxNumber: | 5138817188 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2005 | ||||||||
| LastUpdateDate: | 11/15/2016 | ||||||||
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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 | NP-08305 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LP0808X | NP 08305 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.