Provider Demographics
NPI:1619177557
Name:WILDER, VIRGINIA DAGGETT (PHD, MSN, RN)
Entity Type:Individual
Prefix:DR
First Name:VIRGINIA
Middle Name:DAGGETT
Last Name:WILDER
Suffix:
Gender:F
Credentials:PHD, MSN, RN
Other - Prefix:DR
Other - First Name:VIRGINIA
Other - Middle Name:SUE
Other - Last Name:DAGGETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD, MSN, RN
Mailing Address - Street 1:499 HERITAGE DR
Mailing Address - Street 2:
Mailing Address - City:MACKINAW
Mailing Address - State:IL
Mailing Address - Zip Code:61755-8999
Mailing Address - Country:US
Mailing Address - Phone:309-256-3570
Mailing Address - Fax:
Practice Address - Street 1:1481 W 10TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-2803
Practice Address - Country:US
Practice Address - Phone:317-988-3155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-19
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.304192163W00000X
IN28191988A163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse