Provider Demographics
NPI:1245390376
Name:WILDES, JEANIE M (NP)
Entity Type:Individual
Prefix:MRS
First Name:JEANIE
Middle Name:M
Last Name:WILDES
Suffix:
Gender:F
Credentials:NP
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Mailing Address - Street 1:95 SOLDIERS PASS RD STE B1
Mailing Address - Street 2:
Mailing Address - City:SEDONA
Mailing Address - State:AZ
Mailing Address - Zip Code:86336-4712
Mailing Address - Country:US
Mailing Address - Phone:928-204-4900
Mailing Address - Fax:928-204-4905
Practice Address - Street 1:95 SOLDIERS PASS RD STE B1
Practice Address - Street 2:
Practice Address - City:SEDONA
Practice Address - State:AZ
Practice Address - Zip Code:86336-4712
Practice Address - Country:US
Practice Address - Phone:928-204-4900
Practice Address - Fax:928-204-4905
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZAZAP1131363LF0000X
AZAP1131363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily