Provider Demographics
NPI:1346600558
Name:WILDER-WHITING, COURTNEY (FNP)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:WILDER-WHITING
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:
Other - Last Name:MCENTIRE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:7951 SHOAL CREEK BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78757-7582
Mailing Address - Country:US
Mailing Address - Phone:512-584-8404
Mailing Address - Fax:
Practice Address - Street 1:1509 STONECREEK DR S
Practice Address - Street 2:
Practice Address - City:PICKERINGTON
Practice Address - State:OH
Practice Address - Zip Code:43147
Practice Address - Country:US
Practice Address - Phone:740-653-2500
Practice Address - Fax:740-653-2552
Is Sole Proprietor?:No
Enumeration Date:2016-03-01
Last Update Date:2018-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.18936363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0168022Medicaid