Provider Demographics
NPI:1790496909
Name:WILDMAN, BROOKLYN MARIE (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:BROOKLYN
Middle Name:MARIE
Last Name:WILDMAN
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:BROOKLYN
Other - Middle Name:MARIE
Other - Last Name:EVERMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:928 DIAMOND SPRINGS RD STE 103
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-6601
Mailing Address - Country:US
Mailing Address - Phone:757-395-1975
Mailing Address - Fax:
Practice Address - Street 1:928 DIAMOND SPRINGS RD STE 103
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23455-6601
Practice Address - Country:US
Practice Address - Phone:757-395-1975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-08
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
VA2305215015225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist