Provider Demographics
NPI:1790379618
Name:WILDEMAN, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:WILDEMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10400 FAR VIEW DR
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47712-8946
Mailing Address - Country:US
Mailing Address - Phone:812-306-4757
Mailing Address - Fax:
Practice Address - Street 1:11550 N MERIDIAN ST STE 375-A
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-6956
Practice Address - Country:US
Practice Address - Phone:463-223-5702
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-22
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28203347A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily