Provider Demographics
NPI:1114369527
Name:WILDE, CRISTIN (LPN)
Entity Type:Individual
Prefix:
First Name:CRISTIN
Middle Name:
Last Name:WILDE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3807 CORNELL ST
Mailing Address - Street 2:
Mailing Address - City:HAMBURG
Mailing Address - State:NY
Mailing Address - Zip Code:14075-2719
Mailing Address - Country:US
Mailing Address - Phone:716-208-0232
Mailing Address - Fax:
Practice Address - Street 1:1680 WALDEN AVE
Practice Address - Street 2:
Practice Address - City:CHEEKTOWAGA
Practice Address - State:NY
Practice Address - Zip Code:14225-4914
Practice Address - Country:US
Practice Address - Phone:716-894-7777
Practice Address - Fax:716-894-0604
Is Sole Proprietor?:No
Enumeration Date:2013-07-26
Last Update Date:2013-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY297158164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse