Provider Demographics
NPI:1407323371
Name:WILDER, OLIVIA (HAS)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:WILDER
Suffix:
Gender:F
Credentials:HAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1756 US HIGHWAY 90 W STE 3
Mailing Address - Street 2:
Mailing Address - City:DEFUNIAK SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32433-1449
Mailing Address - Country:US
Mailing Address - Phone:850-892-7343
Mailing Address - Fax:
Practice Address - Street 1:1756 US HIGHWAY 90 W STE 3
Practice Address - Street 2:
Practice Address - City:DEFUNIAK SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32433-1449
Practice Address - Country:US
Practice Address - Phone:850-892-7343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-30
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAS5401237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument SpecialistGroup - Single Specialty