Provider Demographics
NPI:1639845795
Name:WILDWOOD, ROBERT EARL (LPN)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:EARL
Last Name:WILDWOOD
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 E 11TH ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-1559
Mailing Address - Country:US
Mailing Address - Phone:612-558-7273
Mailing Address - Fax:
Practice Address - Street 1:935 KENWOOD AVE
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55811-4951
Practice Address - Country:US
Practice Address - Phone:218-396-3787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-19
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN822435164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse