Provider Demographics
NPI:1497079511
Name:WILDER, JEAN (NP)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:
Last Name:WILDER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:585-597 MERRIMACK STREET
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01854
Mailing Address - Country:US
Mailing Address - Phone:978-322-8500
Mailing Address - Fax:978-446-0248
Practice Address - Street 1:17 WARREN ST
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01852-2216
Practice Address - Country:US
Practice Address - Phone:978-322-8500
Practice Address - Fax:978-446-0248
Is Sole Proprietor?:No
Enumeration Date:2010-03-18
Last Update Date:2010-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA237180363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily