Provider Demographics
NPI:1558831925
Name:WILDER, DAYNA CHINNERS (APRN)
Entity Type:Individual
Prefix:
First Name:DAYNA
Middle Name:CHINNERS
Last Name:WILDER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 421718
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:SC
Mailing Address - Zip Code:29442-4203
Mailing Address - Country:US
Mailing Address - Phone:843-652-8226
Mailing Address - Fax:
Practice Address - Street 1:12117 OCEAN HWY
Practice Address - Street 2:
Practice Address - City:PAWLEYS ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29585-7941
Practice Address - Country:US
Practice Address - Phone:843-237-8231
Practice Address - Fax:843-237-8551
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-28
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC22396363LF0000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP5749Medicaid