Provider Demographics
NPI:1376138644
Name:WILDERN, ELISE SHANNON PEANEY (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:ELISE
Middle Name:SHANNON PEANEY
Last Name:WILDERN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 CANTERBURY DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:MI
Mailing Address - Zip Code:48813-1038
Mailing Address - Country:US
Mailing Address - Phone:517-896-7119
Mailing Address - Fax:
Practice Address - Street 1:3404 PATIENT CARE DR
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48911-4217
Practice Address - Country:US
Practice Address - Phone:517-267-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-08
Last Update Date:2023-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704292079363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily