Provider Demographics
NPI:1467583401
Name:WILDER, GLENDA LEE
Entity Type:Individual
Prefix:
First Name:GLENDA
Middle Name:LEE
Last Name:WILDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:GLENDA
Other - Middle Name:LEE
Other - Last Name:MIRACLE -HURST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:DEPARTMENT 888182
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37995-8182
Mailing Address - Country:US
Mailing Address - Phone:800-355-3565
Mailing Address - Fax:423-714-2355
Practice Address - Street 1:1596 HIGHWAY 33 SOUTH
Practice Address - Street 2:
Practice Address - City:NEW TAZEWELL
Practice Address - State:TN
Practice Address - Zip Code:37825
Practice Address - Country:US
Practice Address - Phone:423-626-8271
Practice Address - Fax:423-626-0688
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator