1639113376 NPI number — MICHELLE WILDER PT

Table of content: MICHELLE WILDER PT (NPI 1639113376)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639113376 NPI number — MICHELLE WILDER PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILDER
Provider First Name:
MICHELLE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
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:
1639113376
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/16/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14007 HICKORY RIDGE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40245-5176
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-777-2965
Provider Business Mailing Address Fax Number:
502-742-5553

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2400 EASTPOINT PKWY STE 130
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40223-4154
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-962-2400
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/15/2006

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: 225100000X , with the licence number:  003773 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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