Provider Demographics
NPI:1629478805
Name:WILDEMAN, ROSEMARY (RN)
Entity Type:Individual
Prefix:
First Name:ROSEMARY
Middle Name:
Last Name:WILDEMAN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5325 W 79TH AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:ARVADA
Mailing Address - State:CO
Mailing Address - Zip Code:80003-2644
Mailing Address - Country:US
Mailing Address - Phone:720-495-9617
Mailing Address - Fax:303-427-5486
Practice Address - Street 1:10065 E HARVARD AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80231-5968
Practice Address - Country:US
Practice Address - Phone:303-614-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-25
Last Update Date:2014-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO204591163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
COY568990Medicaid