Provider Demographics
NPI:1497387724
Name:WILDER, SARA CAITLIN
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:CAITLIN
Last Name:WILDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3410 HASTINGS CIR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40241-2524
Mailing Address - Country:US
Mailing Address - Phone:502-494-8337
Mailing Address - Fax:
Practice Address - Street 1:3410 HASTINGS CIR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40241-2524
Practice Address - Country:US
Practice Address - Phone:502-494-8337
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-05
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program