Basic Information
| Provider Information | |||||||||
| NPI: | 1770577322 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILDER | ||||||||
| FirstName: | BERNICE | ||||||||
| MiddleName: | JOANN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DNP, ARNP, BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 BODIN CIRCLE | ||||||||
| Address2: | DAVID GRANT MEDICAL CENTER | ||||||||
| City: | TRAVIS AFB | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074235174 | ||||||||
| FaxNumber: | 7074235144 | ||||||||
| Practice Location | |||||||||
| Address1: | MADIGAN ARMY MEDICAL CENTER | ||||||||
| Address2: | 9040 JACKSON AVE | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984381336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539823685 | ||||||||
| FaxNumber: | 2539829037 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2005 | ||||||||
| LastUpdateDate: | 05/03/2019 | ||||||||
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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 | 163WP0809X | RN00096394 | WA | N | Nursing Service Providers | Registered Nurse | Psych/Mental Health, Adult | 363LP0808X | AP0003838 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.