Provider Demographics
NPI:1407280100
Name:WILDE, NANCY J (MST)
Entity Type:Individual
Prefix:MS
First Name:NANCY
Middle Name:J
Last Name:WILDE
Suffix:
Gender:F
Credentials:MST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 GREENDALE AVE
Mailing Address - Street 2:
Mailing Address - City:NEEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02494-2028
Mailing Address - Country:US
Mailing Address - Phone:781-444-5144
Mailing Address - Fax:
Practice Address - Street 1:105 CHESTNUT ST. AT NEEDHAM FAMILY CHIRO.
Practice Address - Street 2:SUITE 35
Practice Address - City:NEEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02492
Practice Address - Country:US
Practice Address - Phone:781-444-5144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-29
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2346225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist