Provider Demographics
NPI:1366923104
Name:WILDE, KRISTI KAY (PT)
Entity type:Individual
Prefix:
First Name:KRISTI
Middle Name:KAY
Last Name:WILDE
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 338
Mailing Address - Street 2:
Mailing Address - City:MOORCROFT
Mailing Address - State:WY
Mailing Address - Zip Code:82721-0338
Mailing Address - Country:US
Mailing Address - Phone:307-756-9200
Mailing Address - Fax:
Practice Address - Street 1:101 WEST CROOK STREET
Practice Address - Street 2:
Practice Address - City:MOORCROFT
Practice Address - State:WY
Practice Address - Zip Code:82721
Practice Address - Country:US
Practice Address - Phone:307-756-9200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-28
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PT-0350225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY83-0234097Medicaid
WY83-023497Medicaid