Provider Demographics
NPI:1770859019
Name:WILDE, NANETTE (OTR)
Entity Type:Individual
Prefix:
First Name:NANETTE
Middle Name:
Last Name:WILDE
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 DONNIE AVE
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76541-8918
Mailing Address - Country:US
Mailing Address - Phone:254-634-8505
Mailing Address - Fax:254-781-4312
Practice Address - Street 1:1102 WINKLER AVE
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76542
Practice Address - Country:US
Practice Address - Phone:254-634-8505
Practice Address - Fax:254-781-4312
Is Sole Proprietor?:No
Enumeration Date:2012-03-30
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX113768225X00000X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0031DGOtherBLUE CROSS BLUE SHIELD
TX0944746-02Medicaid
456890Medicare Oscar/Certification