Provider Demographics
NPI:1508447848
Name:WILDER, CAROL A
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:A
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 1:5775 JULIAN AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:NC
Mailing Address - Zip Code:27298-8036
Mailing Address - Country:US
Mailing Address - Phone:336-253-7463
Mailing Address - Fax:
Practice Address - Street 1:2706 N CHURCH ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-3657
Practice Address - Country:US
Practice Address - Phone:336-272-9990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-19
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC376682376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide