Provider Demographics
NPI:1154678548
Name:WILDER, JASHONDA D (LPN)
Entity Type:Individual
Prefix:MS
First Name:JASHONDA
Middle Name:D
Last Name:WILDER
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 1:2120 RANDALL AVE APT 10B
Mailing Address - Street 2:10B
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10473-1708
Mailing Address - Country:US
Mailing Address - Phone:347-293-6803
Mailing Address - Fax:
Practice Address - Street 1:2120 RANDALL AVE APT 10B
Practice Address - Street 2:10B
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10473-1708
Practice Address - Country:US
Practice Address - Phone:347-293-6803
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-06
Last Update Date:2012-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7578300164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse