Provider Demographics
NPI:1346741105
Name:WILDER, DAWN MITCHELL
Entity Type:Individual
Prefix:
First Name:DAWN
Middle Name:MITCHELL
Last Name:WILDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1507 EDEN ISLE BLVD NE APT 100
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33704-1713
Mailing Address - Country:US
Mailing Address - Phone:727-771-5783
Mailing Address - Fax:
Practice Address - Street 1:600 1ST AVE N STE 201
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-3609
Practice Address - Country:US
Practice Address - Phone:727-895-9622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-26
Last Update Date:2018-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator