Provider Demographics
NPI:1114223674
Name:WILD, TAMMY M
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:M
Last Name:WILD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 W CHARLESTON BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-2329
Mailing Address - Country:US
Mailing Address - Phone:702-383-2000
Mailing Address - Fax:
Practice Address - Street 1:1800 W CHARLESTON BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-2329
Practice Address - Country:US
Practice Address - Phone:702-383-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-01
Last Update Date:2015-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV32050DI-1133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered