Provider Demographics
NPI:1487706222
Name:WILDER, PHYLLIS (RN)
Entity type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:
Last Name:WILDER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2132 MILL CROSSING DR APT 206
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-1263
Mailing Address - Country:US
Mailing Address - Phone:757-894-8703
Mailing Address - Fax:757-961-6568
Practice Address - Street 1:2132 MILL CROSSING DR APT 206
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-1263
Practice Address - Country:US
Practice Address - Phone:757-961-6592
Practice Address - Fax:757-961-6568
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-023054163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management