Provider Demographics
NPI:1245581602
Name:WILDER, JANICE MAY (NP)
Entity Type:Individual
Prefix:
First Name:JANICE
Middle Name:MAY
Last Name:WILDER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2183 E HIGHWAY 5
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30116-7716
Mailing Address - Country:US
Mailing Address - Phone:770-314-2018
Mailing Address - Fax:
Practice Address - Street 1:2183 E HIGHWAY 5
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30116-7716
Practice Address - Country:US
Practice Address - Phone:770-314-2018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-26
Last Update Date:2016-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA150905363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner