Provider Demographics
NPI:1174120265
Name:WILDER, SHAWANDA RENE
Entity type:Individual
Prefix:
First Name:SHAWANDA
Middle Name:RENE
Last Name:WILDER
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 1:616 N 10TH ST
Mailing Address - Street 2:
Mailing Address - City:IMMOKALEE
Mailing Address - State:FL
Mailing Address - Zip Code:34142-2908
Mailing Address - Country:US
Mailing Address - Phone:239-290-0114
Mailing Address - Fax:
Practice Address - Street 1:2489 DIPLOMAT PKWY E
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33909-5422
Practice Address - Country:US
Practice Address - Phone:239-652-1800
Practice Address - Fax:239-652-1932
Is Sole Proprietor?:No
Enumeration Date:2020-10-02
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLW436-796-90--922-1OtherVETERAN AFFAIRS