Provider Demographics
NPI:1598013534
Name:WILDE, JODI L (NP)
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:L
Last Name:WILDE
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 1:4202 W OAKWOOD PARK CT STE 200
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53132-9565
Mailing Address - Country:US
Mailing Address - Phone:414-423-5250
Mailing Address - Fax:
Practice Address - Street 1:4202 W OAKWOOD PARK CT STE 200
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:WI
Practice Address - Zip Code:53132-9565
Practice Address - Country:US
Practice Address - Phone:414-423-5250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-23
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI151348363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100026312Medicaid