Provider Demographics
NPI:1710388301
Name:WILDES, TERRI H (NP-C)
Entity Type:Individual
Prefix:
First Name:TERRI
Middle Name:H
Last Name:WILDES
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2410N OAK ST
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-2533
Mailing Address - Country:US
Mailing Address - Phone:229-241-7546
Mailing Address - Fax:229-469-5722
Practice Address - Street 1:2410N OAK ST
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-2533
Practice Address - Country:US
Practice Address - Phone:229-241-7546
Practice Address - Fax:229-469-5722
Is Sole Proprietor?:No
Enumeration Date:2014-09-15
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN076912363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner