Basic Information
| Provider Information | |||||||||
| NPI: | 1912466756 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILD | ||||||||
| FirstName: | CECILIA | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | APN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | QUIGLEY | ||||||||
| OtherFirstName: | CECILIA | ||||||||
| OtherMiddleName: | ANNE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | APRN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 15164 EYRE CIR | ||||||||
| Address2: | |||||||||
| City: | PLAINFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605442433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305899375 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 24600 W 127TH ST STE B325 | ||||||||
| Address2: | |||||||||
| City: | PLAINFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605859527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157319100 | ||||||||
| FaxNumber: | 8157319110 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2019 | ||||||||
| LastUpdateDate: | 06/15/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 209.019027 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.