1396867750 NPI number — MS. JENNIFER L WILD OTR

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396867750 NPI number — MS. JENNIFER L WILD OTR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILD
Provider First Name:
JENNIFER
Provider Middle Name:
L
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
OTR
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396867750
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/22/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10702 SW ELSINORE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT SAINT LUCIE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34987-2149
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
772-336-6928
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1483 SW BOUGAINVILLEA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORT SAINT LUCIE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34953-7302
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
772-336-6928
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X , with the licence number:  OT8477 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 884456900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com