Provider Demographics
NPI:1619906294
Name:WILDE, STEFANIE LORRAINE (DC)
Entity Type:Individual
Prefix:DR
First Name:STEFANIE
Middle Name:LORRAINE
Last Name:WILDE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:STEFANIE
Other - Middle Name:LORRAINE
Other - Last Name:HAMBY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:1541 SE 17TH ST.
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34471
Mailing Address - Country:US
Mailing Address - Phone:352-400-9272
Mailing Address - Fax:
Practice Address - Street 1:1541 SE 17TH ST.
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471
Practice Address - Country:US
Practice Address - Phone:352-400-9272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3921111N00000X
IL038008963111N00000X
FLCH10052111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL10132196OtherBCBS
IL038008963Medicaid
IL213155Medicare PIN
IL038008963Medicaid