Provider Demographics
NPI:1215202130
Name:WILDER, EVELYN (FNP-BC)
Entity Type:Individual
Prefix:
First Name:EVELYN
Middle Name:
Last Name:WILDER
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3012 NOTRE DAME DR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95826-3512
Mailing Address - Country:US
Mailing Address - Phone:916-837-1662
Mailing Address - Fax:
Practice Address - Street 1:5821 JAMESON CT
Practice Address - Street 2:
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-0890
Practice Address - Country:US
Practice Address - Phone:916-486-0411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-09
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA698623163WC0200X
CANP 20906363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine