Provider Demographics
NPI:1285853101
Name:WILD, THERESA EILEEN (RN)
Entity Type:Individual
Prefix:MISS
First Name:THERESA
Middle Name:EILEEN
Last Name:WILD
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1280
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:CT
Mailing Address - Zip Code:06011-1280
Mailing Address - Country:US
Mailing Address - Phone:860-583-5858
Mailing Address - Fax:860-584-9962
Practice Address - Street 1:440 N MAIN ST # C
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010-4990
Practice Address - Country:US
Practice Address - Phone:860-583-5858
Practice Address - Fax:860-584-9962
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTE57029163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult