Provider Demographics
NPI:1164120242
Name:WILT, MANDI JO (MSN, APRN, FNP-C)
Entity Type:Individual
Prefix:
First Name:MANDI
Middle Name:JO
Last Name:WILT
Suffix:
Gender:F
Credentials:MSN, APRN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 KEYS ST
Mailing Address - Street 2:
Mailing Address - City:KEYSER
Mailing Address - State:WV
Mailing Address - Zip Code:26726-3619
Mailing Address - Country:US
Mailing Address - Phone:304-790-2033
Mailing Address - Fax:
Practice Address - Street 1:164 PARKVIEW DR
Practice Address - Street 2:
Practice Address - City:KEYSER
Practice Address - State:WV
Practice Address - Zip Code:26726-2313
Practice Address - Country:US
Practice Address - Phone:304-597-2494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-20
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV104532363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty