Provider Demographics
NPI:1003199480
Name:WILDES, DEANNA M (RN, BSN)
Entity Type:Individual
Prefix:
First Name:DEANNA
Middle Name:M
Last Name:WILDES
Suffix:
Gender:F
Credentials:RN, BSN
Other - Prefix:
Other - First Name:DEANNA
Other - Middle Name:M
Other - Last Name:MAYBERRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 116336
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-6336
Mailing Address - Country:US
Mailing Address - Phone:912-352-8346
Mailing Address - Fax:912-355-1414
Practice Address - Street 1:4750 WATERS AVENUE
Practice Address - Street 2:SUITE 500
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31404-6261
Practice Address - Country:US
Practice Address - Phone:912-352-8346
Practice Address - Fax:912-355-1414
Is Sole Proprietor?:No
Enumeration Date:2011-09-22
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN077963363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003115053FMedicaid
GA003115053AMedicaid
GA003115053CMedicaid
GA003115053BMedicaid